MEDICARE: MRS. CAROL JEAN WILBUR 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	007310-1	NY

General Provider Information

NPI Number	:	1336425842
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CAROL JEAN WILBUR CCC-SLP

Provider Business Mailing Address
First Line	:	5489 LAKE RD S
Second Line	:
City	:	BROCKPORT
State	:	NY
Zip	:	14420-9754
Country	:	US
Telephone Number	:	585-247-5050
Fax Number	:

Provider Business Practice Location Address
First Line	:	5489 LAKE RD S
Second Line	:
City	:	BROCKPORT
State	:	NY
Zip	:	14420-9754
Country	:	US
Telephone Number	:	585-247-5050
Fax Number	:

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

Provider Enumeration Date	:	10/28/2011
Last Update Date	:	10/28/2011

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