Provider Demographics
NPI:1194288225
Name:WILSON, TRACIE LYNN (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:TRACIE
Middle Name:LYNN
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 1:2070 S SMOKERISE WAY
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29466-8635
Mailing Address - Country:US
Mailing Address - Phone:602-717-6346
Mailing Address - Fax:
Practice Address - Street 1:2070 S SMOKERISE WAY
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29466-8635
Practice Address - Country:US
Practice Address - Phone:602-717-6346
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-06
Last Update Date:2019-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6050235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty