Provider Demographics
NPI:1336631423
Name:WILSON, STEPHANIE ANN (CCC-SLP, CBIS)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ANN
Last Name:WILSON
Suffix:
Gender:F
Credentials:CCC-SLP, CBIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 N MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48602-4316
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:515 N MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-4316
Practice Address - Country:US
Practice Address - Phone:989-583-2715
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-04
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101002643235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist