MEDICARE: MRS. GRACE CHRISTINE 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
1	235Z00000X	Speech-Language Pathologist	2138	OK
2	235Z00000X	Speech-Language Pathologist	01025271

General Provider Information

NPI Number	:	1841397569
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. GRACE CHRISTINE WILSON MS CCC SLP

Provider Business Mailing Address
First Line	:	3706 N WILLIAMS
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-2939
Country	:	US
Telephone Number	:	405-946-6225
Fax Number	:

Provider Business Practice Location Address
First Line	:	3706 N WILLIAMS
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-2939
Country	:	US
Telephone Number	:	405-946-6225
Fax Number	:

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

Provider Enumeration Date	:	09/17/2006
Last Update Date	:	07/08/2007

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