Provider Demographics
NPI:1780982678
Name:WILSON, PATRICIA SHANAHAN (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:SHANAHAN
Last Name:WILSON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4931 OLD DOMINION DR
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22207-2833
Mailing Address - Country:US
Mailing Address - Phone:703-623-1806
Mailing Address - Fax:703-241-1910
Practice Address - Street 1:4931 OLD DOMINION DR
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22207-2833
Practice Address - Country:US
Practice Address - Phone:703-623-1806
Practice Address - Fax:703-241-1910
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-02
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202004319235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist