MEDICARE: MRS. SAMANTHA S WILSON M.A.C.C.C-SLP

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	SP-869	NV

General Provider Information

NPI Number	:	1134377682
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SAMANTHA S WILSON M.A.C.C.C-SLP

Provider Business Mailing Address
First Line	:	7500 W LAKE MEAD BLVD
Second Line	:	#128
City	:	LAS VEGAS
State	:	NV
Zip	:	89128-0297
Country	:	US
Telephone Number	:	702-592-2935
Fax Number	:	702-243-4281

Provider Business Practice Location Address
First Line	:	7500 W LAKE MEAD BLVD
Second Line	:	#128
City	:	LAS VEGAS
State	:	NV
Zip	:	89128-0297
Country	:	US
Telephone Number	:	702-592-2935
Fax Number	:	702-243-4281

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

Provider Enumeration Date	:	09/08/2008
Last Update Date	:	09/08/2008

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