MEDICARE: ANISSIA WILSON M.S, C.F./S.L.P.

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	119865	TX
2	2355S0801X	Speech-Language Assistant

General Provider Information

NPI Number	:	1699275248
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANISSIA WILSON M.S, C.F./S.L.P.

Provider Business Mailing Address
First Line	:	2351 RIVER VALLEY DR
Second Line	:
City	:	MISSOURI CITY
State	:	TX
Zip	:	77489-5011
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2351 RIVER VALLEY DR
Second Line	:
City	:	MISSOURI CITY
State	:	TX
Zip	:	77489-5011
Country	:	US
Telephone Number	:	281-509-1086
Fax Number	:

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

Provider Enumeration Date	:	02/20/2018
Last Update Date	:	11/22/2022

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