Healthcare Provider Details

I. General information

NPI: 1750629937
Provider Name (Legal Business Name): ELIZABETH WILSON M.A., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2013
Last Update Date: 01/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 W HAYCRAFT AVE SUITE D4
COEUR D ALENE ID
83815-8105
US

IV. Provider business mailing address

411 W HAYCRAFT AVE SUITE D4
COEUR D ALENE ID
83815-8105
US

V. Phone/Fax

Practice location:
  • Phone: 208-664-2468
  • Fax: 208-667-6239
Mailing address:
  • Phone: 208-664-2468
  • Fax: 208-667-6239

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP-2219
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberLL60026217
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: