Provider Demographics
NPI:1427529304
Name:WILSON, ROBERTA ANNE (MA CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:ROBERTA
Middle Name:ANNE
Last Name:WILSON
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12263 EAGLES POINT LN
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:VA
Mailing Address - Zip Code:23005-7870
Mailing Address - Country:US
Mailing Address - Phone:804-798-1516
Mailing Address - Fax:
Practice Address - Street 1:200 BERKLEY ST
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:VA
Practice Address - Zip Code:23005-1302
Practice Address - Country:US
Practice Address - Phone:804-365-4500
Practice Address - Fax:804-365-4680
Is Sole Proprietor?:No
Enumeration Date:2018-12-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202008004235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist