MEDICARE: GRETCHEN M WILSON

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	3578	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1497731012
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRETCHEN M WILSON

Provider Business Mailing Address
First Line	:	5440 COPPER SPRINGS LN
Second Line	:
City	:	CUMMING
State	:	GA
Zip	:	30040-5626
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5440 COPPER SPRINGS LN
Second Line	:
City	:	CUMMING
State	:	GA
Zip	:	30040-5626
Country	:	US
Telephone Number	:	704-756-9324
Fax Number	:

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

Provider Enumeration Date	:	12/15/2005
Last Update Date	:	08/13/2013

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Directions to “ GRETCHEN M WILSON ” Practice Location

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