Provider Demographics
NPI:1295974442
Name:WILSON, BRANDI (SLP)
Entity type:Individual
Prefix:MRS
First Name:BRANDI
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 SOUTH 5TH ST
Mailing Address - Street 2:
Mailing Address - City:HEBER SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:72543-3816
Mailing Address - Country:US
Mailing Address - Phone:501-250-5166
Mailing Address - Fax:888-898-8972
Practice Address - Street 1:112 SOUTH 5TH ST.
Practice Address - Street 2:
Practice Address - City:HERBER SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:72543-3816
Practice Address - Country:US
Practice Address - Phone:501-547-9994
Practice Address - Fax:888-898-8972
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-11
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARSP#2056235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR175067721Medicaid