Provider Demographics
NPI:1770309585
Name:WILSON, ELIZABETH MAE (CCC-SLP)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:MAE
Last Name:WILSON
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 HESTER RD
Mailing Address - Street 2:
Mailing Address - City:MATHISTON
Mailing Address - State:MS
Mailing Address - Zip Code:39752-6855
Mailing Address - Country:US
Mailing Address - Phone:662-744-2825
Mailing Address - Fax:
Practice Address - Street 1:310 AUTUMN RIDGE DR
Practice Address - Street 2:
Practice Address - City:KOSCIUSKO
Practice Address - State:MS
Practice Address - Zip Code:39090-3242
Practice Address - Country:US
Practice Address - Phone:662-289-7044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-26
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS-4954235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist