Provider Demographics
NPI:1205135753
Name:NICE, WILSON (MA, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:WILSON
Middle Name:
Last Name:NICE
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:BEKAH
Other - Middle Name:WILSON
Other - Last Name:NICE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, CCC-SLP
Mailing Address - Street 1:409 N CALIFORNIA ST
Mailing Address - Street 2:
Mailing Address - City:SOCORRO
Mailing Address - State:NM
Mailing Address - Zip Code:87801-4208
Mailing Address - Country:US
Mailing Address - Phone:505-907-1902
Mailing Address - Fax:833-448-2997
Practice Address - Street 1:409 N CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:SOCORRO
Practice Address - State:NM
Practice Address - Zip Code:87801-4208
Practice Address - Country:US
Practice Address - Phone:505-907-1902
Practice Address - Fax:833-448-2997
Is Sole Proprietor?:No
Enumeration Date:2011-03-23
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC15254235Z00000X
NM5194235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1184855181Medicaid
NM03260720002-GRTMedicaid