=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063923605
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARLA JAN WILSON MS, CCC-SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2017
-----------------------------------------------------
Last Update Date | 10/23/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 LAKE RD APT 1106
-----------------------------------------------------
City | BELTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76513-1537
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 254-899-5201
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 900 WASHINGTON AVE STE 602
-----------------------------------------------------
City | WACO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76701-1283
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 254-296-9792
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 106922
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------