Provider Demographics
NPI:1740981711
Name:WILSON, CHARLES BRANDON (SLP)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:BRANDON
Last Name:WILSON
Suffix:
Gender:M
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6051 APPLECROSS DR
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-6493
Mailing Address - Country:US
Mailing Address - Phone:562-715-8105
Mailing Address - Fax:
Practice Address - Street 1:1007 E COOLEY DR # 107
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-3901
Practice Address - Country:US
Practice Address - Phone:909-388-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-15
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist