Provider Demographics
NPI:1063923605
Name:WILSON, MARLA JAN (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:MARLA
Middle Name:JAN
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 1:900 WASHINGTON AVE STE 602
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76701-1283
Mailing Address - Country:US
Mailing Address - Phone:254-296-9792
Mailing Address - Fax:
Practice Address - Street 1:200 LAKE RD APT 1106
Practice Address - Street 2:
Practice Address - City:BELTON
Practice Address - State:TX
Practice Address - Zip Code:76513-1537
Practice Address - Country:US
Practice Address - Phone:254-899-5201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-23
Last Update Date:2017-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX106922235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist