Provider Demographics
NPI:1780968909
Name:WILSON, COURTNEY R (SLP)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:R
Last Name:WILSON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:R
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:SLP
Mailing Address - Street 1:605 JEFFERSON DAVIS HWY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22401-8403
Mailing Address - Country:US
Mailing Address - Phone:540-446-2654
Mailing Address - Fax:540-371-3748
Practice Address - Street 1:605 JEFFERSON DAVIS HWY
Practice Address - Street 2:SUITE 101
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-8403
Practice Address - Country:US
Practice Address - Phone:540-446-2654
Practice Address - Fax:540-371-3748
Is Sole Proprietor?:No
Enumeration Date:2011-10-06
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202005998235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist