MEDICARE: BRIGETTE 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	SP5583	OH

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	366525	OTHER	OH	MEDICARE PTAN

Other Identifiers

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

General Provider Information

NPI Number	:	1518363514
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIGETTE WILSON

Provider Business Mailing Address
First Line	:	2121 EUCLID AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44115-2214
Country	:	US
Telephone Number	:	216-687-3806
Fax Number	:

Provider Business Practice Location Address
First Line	:	2121 EUCLID AVE # IM269
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44115-2214
Country	:	US
Telephone Number	:	216-687-3806
Fax Number	:

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

Provider Enumeration Date	:	11/18/2014
Last Update Date	:	02/11/2022

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Directions to “ BRIGETTE WILSON ” Practice Location

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