Provider Demographics
NPI:1063808640
Name:WILSON, MEGAN GAUTHEY (MS, CCC/SLP)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:GAUTHEY
Last Name:WILSON
Suffix:
Gender:F
Credentials:MS, CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3751 WILL SCARLET RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27104-1648
Mailing Address - Country:US
Mailing Address - Phone:281-610-3296
Mailing Address - Fax:
Practice Address - Street 1:3751 WILL SCARLET RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27104-1648
Practice Address - Country:US
Practice Address - Phone:281-610-3296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-10
Last Update Date:2015-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11063235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist