MEDICARE: DESTINY 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	SP-3888	NV

General Provider Information

NPI Number	:	1649888579
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DESTINY WILSON

Provider Business Mailing Address
First Line	:	9121 W RUSSELL RD STE 115
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89148-1238
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4370 S GRAND CANYON DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89147-7107
Country	:	US
Telephone Number	:	702-850-2691
Fax Number	:

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

Provider Enumeration Date	:	07/16/2020
Last Update Date	:	06/13/2024

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Directions to “ DESTINY WILSON ” Practice Location

Language	Start Address	Practice Location

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