Provider Demographics
NPI:1841450095
Name:WILSON, MICHELE DRISKO (PHD)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:DRISKO
Last Name:WILSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4010 BARRANCA PARKWAY
Mailing Address - Street 2:STE 220
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92604-4711
Mailing Address - Country:US
Mailing Address - Phone:949-857-6051
Mailing Address - Fax:949-857-0941
Practice Address - Street 1:4010 BARRANCA PARKWAY
Practice Address - Street 2:STE 220
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92604-4711
Practice Address - Country:US
Practice Address - Phone:949-857-6051
Practice Address - Fax:949-857-0941
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-11
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAU1215231H00000X, 237600000X
CASP8495235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
R82262Medicare UPIN
AUD1215Medicare PIN