Provider Demographics
NPI:1932396397
Name:WILSON, MICHAELYN (MC/CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MICHAELYN
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:MC/CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 HANWORTH LN
Mailing Address - Street 2:
Mailing Address - City:DANIELS
Mailing Address - State:WV
Mailing Address - Zip Code:25832-9029
Mailing Address - Country:US
Mailing Address - Phone:304-345-6313
Mailing Address - Fax:304-763-7954
Practice Address - Street 1:120 HANWORTH LN
Practice Address - Street 2:
Practice Address - City:DANIELS
Practice Address - State:WV
Practice Address - Zip Code:25832-9029
Practice Address - Country:US
Practice Address - Phone:304-345-6313
Practice Address - Fax:304-763-7954
Is Sole Proprietor?:No
Enumeration Date:2007-10-01
Last Update Date:2010-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSLP-1289235Z00000X
OHSP9302235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30610026Medicaid