Provider Demographics
NPI:1932453412
Name:WILSON, JOANN (SLP)
Entity Type:Individual
Prefix:
First Name:JOANN
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5137 ANGEL FIRE RD APT 211
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-1947
Mailing Address - Country:US
Mailing Address - Phone:817-478-0668
Mailing Address - Fax:
Practice Address - Street 1:3505 FOREST HILL CIR
Practice Address - Street 2:
Practice Address - City:FOREST HILL
Practice Address - State:TX
Practice Address - Zip Code:76140-1200
Practice Address - Country:US
Practice Address - Phone:682-730-6840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-05
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX106556235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX308552401Medicaid
TX82S247OtherBLUE CROSS/BLUE SHIELD