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General NPI Number Information
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NPI Number | 1770618134
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Entity Type | Individual
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Provider Name | JUDITH ANN WILSON CCC SLP
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Gender | Female
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Dates
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Enumeration Date | 02/23/2007
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Last Update Date | 02/19/2009
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Provider Practice Location Address
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Address Line | 301 S WASHINGTON ST SCHOOL DIST R 4 LAMONTE
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City | LA MONTE
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State | MO
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Zip | 65337-1183
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Country | US
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Telephone | 660-347-5439
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Fax | 660-347-5467
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Provider Business Mailing Address
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Address Line | 301 S WASHINGTON ST
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City | LA MONTE
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State | MO
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Zip | 65337-1183
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Country | US
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Telephone | 660-347-5439
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Fax | 660-347-5467
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | 2004013319
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License Number State | MO
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