Provider Demographics
NPI:1700291432
Name:WILSON, MARY (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4782 CARRIAGE DR
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:OH
Mailing Address - Zip Code:45040-8708
Mailing Address - Country:US
Mailing Address - Phone:440-759-1552
Mailing Address - Fax:
Practice Address - Street 1:4782 CARRIAGE DR
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:OH
Practice Address - Zip Code:45040-8708
Practice Address - Country:US
Practice Address - Phone:440-759-1552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-20
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2014298235Z00000X
OHSP11576235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2187155Medicaid
OHAB7360731Medicare PIN