Provider Demographics
NPI:1720249287
Name:WILSON, TANYSHA GIBBS (MA CCC-SLP L)
Entity Type:Individual
Prefix:MRS
First Name:TANYSHA
Middle Name:GIBBS
Last Name:WILSON
Suffix:
Gender:F
Credentials:MA CCC-SLP L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 HUTCHINSON AVE
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29505
Mailing Address - Country:US
Mailing Address - Phone:843-664-0372
Mailing Address - Fax:
Practice Address - Street 1:314 HUTCHINSON AVE
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29505
Practice Address - Country:US
Practice Address - Phone:843-664-0372
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-18
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2797235Z00000X
MD09141511235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist