Provider Demographics
NPI:1669875233
Name:WILFONG, LAURA ELIZABETH (MED, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:ELIZABETH
Last Name:WILFONG
Suffix:
Gender:F
Credentials:MED, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 JENNINGS MILL RD
Mailing Address - Street 2:
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-7238
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1305 JENNINGS MILL RD STE 170
Practice Address - Street 2:
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-0037
Practice Address - Country:US
Practice Address - Phone:706-552-1920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-26
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP008310235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist