MEDICARE: MRS. BRANDY L WILSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	146009590	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1174846455
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. BRANDY L WILSON

Provider Business Mailing Address
First Line	:	836 S BISHOP ST
Second Line	:	GARDEN APT
City	:	CHICAGO
State	:	IL
Zip	:	60607-4022
Country	:	US
Telephone Number	:	814-598-9729
Fax Number	:

Provider Business Practice Location Address
First Line	:	836 S BISHOP ST
Second Line	:	GARDEN APT
City	:	CHICAGO
State	:	IL
Zip	:	60607-4022
Country	:	US
Telephone Number	:	814-598-9729
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/01/2010
Last Update Date	:	03/01/2010

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