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NPI Code Detail

MEDICARE: MS. MARIE ANTONETTE WILSON MS CCC SLP

MEDICARE: MS. MARIE ANTONETTE WILSON MS CCC SLP
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
1235Z00000XSpeech-Language Pathologist104607TX

General Provider Information

NPI Number : 1538461587
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. MARIE ANTONETTE WILSON MS CCC SLP
Provider Business Mailing Address
First Line : 411 SW 24TH ST
Second Line :
City : SAN ANTONIO
State : TX
Zip : 78207-4617
Country : US
Telephone Number : 210-431-3938
Fax Number : 210-434-9360
Provider Business Practice Location Address
First Line : 411 SW 24TH ST
Second Line :
City : SAN ANTONIO
State : TX
Zip : 78207-4617
Country : US
Telephone Number : 210-431-3938
Fax Number : 210-434-9360
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/24/2010
Last Update Date : 11/24/2010

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