Provider Demographics
NPI:1104067396
Name:WILSON, JOAN ESSE (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:JOAN
Middle Name:ESSE
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 1:4801 LANG AVE NE STE 110
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-4475
Mailing Address - Country:US
Mailing Address - Phone:505-410-1461
Mailing Address - Fax:
Practice Address - Street 1:4801 LANG AVE NE STE 110
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4475
Practice Address - Country:US
Practice Address - Phone:505-410-1461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-17
Last Update Date:2009-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4236235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist