MEDICARE: ANGELINA MARIA WILSON M.S. CCC-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	4611-154	WI

General Provider Information

NPI Number	:	1235786054
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANGELINA MARIA WILSON M.S. CCC-SLP

Provider Business Mailing Address
First Line	:	5800 GRANITE PKWY STE 1000
Second Line	:
City	:	PLANO
State	:	TX
Zip	:	75024-6619
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	250 LAWRENCE AVE
Second Line	:
City	:	PARK FALLS
State	:	WI
Zip	:	54552-1431
Country	:	US
Telephone Number	:	715-762-2449
Fax Number	:

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

Provider Enumeration Date	:	08/26/2019
Last Update Date	:	08/17/2021

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