MEDICARE: SOPHIA 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

General Provider Information

NPI Number	:	1699498881
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SOPHIA WILSON

Provider Business Mailing Address
First Line	:	327 OLD HIGHWAY 431 STE C
Second Line	:
City	:	HAMPTON COVE
State	:	AL
Zip	:	35763-9474
Country	:	US
Telephone Number	:	256-517-9277
Fax Number	:

Provider Business Practice Location Address
First Line	:	200 LIME QUARRY RD
Second Line	:
City	:	MADISON
State	:	AL
Zip	:	35758-8961
Country	:	US
Telephone Number	:	256-542-1970
Fax Number	:

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

Provider Enumeration Date	:	09/22/2022
Last Update Date	:	09/22/2022

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Directions to “ SOPHIA WILSON ” Practice Location

Language	Start Address	Practice Location

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