MEDICARE: CHRISTINE WILSON SPEECH LANGUAGE PATHOLOGY LLC

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	261QH0700X	Hearing and Speech Clinic/Center	SA 6126	FL

General Provider Information

NPI Number	:	1548508054
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHRISTINE WILSON SPEECH LANGUAGE PATHOLOGY LLC

Provider Business Mailing Address
First Line	:	17427 BRIDGE HILL CT
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33647
Country	:	US
Telephone Number	:	813-279-2737
Fax Number	:	813-279-2737

Provider Business Practice Location Address
First Line	:	5009 BELMONT RD
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33647-1319
Country	:	US
Telephone Number	:	813-956-8921
Fax Number	:

Authorized Official
Title or Position	:	SPEECH LANGUAGE PATHOLOGIST/MANAGER
Name	:	MRS. CHRISTINE ANN WILSON
Credential	:	M.S. C.C.C.-SLP
Telephone Number	:	813-956-8921

Provider Enumeration Date	:	01/18/2013
Last Update Date	:	01/18/2013

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