Healthcare Provider Details

I. General information

NPI: 1790291987
Provider Name (Legal Business Name): HEATHER WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/26/2017
Last Update Date: 12/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5979 PARTLOW RD
SPOTSYLVANIA VA
22551-3070
US

IV. Provider business mailing address

5979 PARTLOW RD
SPOTSYLVANIA VA
22551-3070
US

V. Phone/Fax

Practice location:
  • Phone: 540-582-5142
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2203000692
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: