Healthcare Provider Details

I. General information

NPI: 1295042729
Provider Name (Legal Business Name): MISS WHITNEY ROXANNE WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2010
Last Update Date: 09/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

448 SIDNEY BAKER S STE 103
KERRVILLE TX
78028-5980
US

IV. Provider business mailing address

5700 TAPADERA TRACE LN APT. 624
AUSTIN TX
78727-6301
US

V. Phone/Fax

Practice location:
  • Phone: 830-896-3130
  • Fax:
Mailing address:
  • Phone: 830-591-3925
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number35674
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: