Healthcare Provider Details

I. General information

NPI: 1366089989
Provider Name (Legal Business Name): CALEB JOSEPH WILSON M.A., CCC-SLP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2019
Last Update Date: 08/25/2023
Certification Date: 08/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

416 ALBEMARLE SQ
CHARLOTTESVILLE VA
22901-7400
US

IV. Provider business mailing address

504 ALBEMARLE SQ
CHARLOTTESVILLE VA
22901-7405
US

V. Phone/Fax

Practice location:
  • Phone: 434-220-0021
  • Fax: 434-465-6843
Mailing address:
  • Phone: 434-817-7848
  • Fax: 434-465-6834

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2202010379
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number0003776
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: