=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124968086
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STACEY M WILSON M.A., CCC-SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2026
-----------------------------------------------------
Last Update Date | 03/31/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 915 E SUNRISE AVE
-----------------------------------------------------
City | THOMASVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27360-4945
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-474-4160
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7410 FARMBROOK PL
-----------------------------------------------------
City | THOMASVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27360-8377
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | 6824
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------