Provider Demographics
NPI:1720502909
Name:WILSON, TRINA RENEE (SPEECH LANGUAGE PATH)
Entity Type:Individual
Prefix:
First Name:TRINA
Middle Name:RENEE
Last Name:WILSON
Suffix:
Gender:F
Credentials:SPEECH LANGUAGE PATH
Other - Prefix:
Other - First Name:TRINA
Other - Middle Name:RENEE
Other - Last Name:BRANCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SPEECH LANGUAGE PATH
Mailing Address - Street 1:1271 NE HIGHWAY 99W # 124
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128-2720
Mailing Address - Country:US
Mailing Address - Phone:509-868-8944
Mailing Address - Fax:
Practice Address - Street 1:201 SE TIDE AVE
Practice Address - Street 2:
Practice Address - City:LINCOLN CITY
Practice Address - State:OR
Practice Address - Zip Code:97367-3058
Practice Address - Country:US
Practice Address - Phone:509-868-8944
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-31
Last Update Date:2017-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR12754235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist