Provider Demographics
NPI:1770618134
Name:WILSON, JUDITH ANN (CCC SLP)
Entity type:Individual
Prefix:MRS
First Name:JUDITH
Middle Name:ANN
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 1:301 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:LA MONTE
Mailing Address - State:MO
Mailing Address - Zip Code:65337-1183
Mailing Address - Country:US
Mailing Address - Phone:660-347-5439
Mailing Address - Fax:660-347-5467
Practice Address - Street 1:301 S WASHINGTON ST
Practice Address - Street 2:SCHOOL DIST R 4 LAMONTE
Practice Address - City:LA MONTE
Practice Address - State:MO
Practice Address - Zip Code:65337-1183
Practice Address - Country:US
Practice Address - Phone:660-347-5439
Practice Address - Fax:660-347-5467
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2009-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004013319235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO463311225Medicaid