MEDICARE: CYNTHIA CAMP WILSON MSCCCSLPL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	SL004048L	PA

General Provider Information

NPI Number	:	1114046828
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CYNTHIA CAMP WILSON MSCCCSLPL

Provider Business Mailing Address
First Line	:	1928 HERTFORD DR
Second Line	:
City	:	SOUTH PARK
State	:	PA
Zip	:	15129-8961
Country	:	US
Telephone Number	:	412-655-3148
Fax Number	:

Provider Business Practice Location Address
First Line	:	1928 HERTFORD DR
Second Line	:
City	:	SOUTH PARK
State	:	PA
Zip	:	15129-8961
Country	:	US
Telephone Number	:	412-655-3148
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/28/2007
Last Update Date	:	07/08/2007

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