MEDICARE: LISA 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	326	AR

General Provider Information

NPI Number	:	1497916761
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA WILSON

Provider Business Mailing Address
First Line	:	205 WEDGEWOOD TER
Second Line	:
City	:	HOT SPRINGS
State	:	AR
Zip	:	71901-7321
Country	:	US
Telephone Number	:	501-318-1409
Fax Number	:

Provider Business Practice Location Address
First Line	:	2837 MALVERN AVE
Second Line	:
City	:	HOT SPRINGS
State	:	AR
Zip	:	71901-8321
Country	:	US
Telephone Number	:	501-262-1724
Fax Number	:

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

Provider Enumeration Date	:	06/19/2008
Last Update Date	:	06/19/2008

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Directions to “ LISA WILSON ” Practice Location

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