Provider Demographics
NPI:1588385629
Name:WILSON, LAUREL JANE (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:LAUREL
Middle Name:JANE
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 1:5017 MANETT ST # 301
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75206-6749
Mailing Address - Country:US
Mailing Address - Phone:901-233-1846
Mailing Address - Fax:
Practice Address - Street 1:5017 MANETT ST # 301
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75206-6749
Practice Address - Country:US
Practice Address - Phone:901-233-1846
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-07
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX117773235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist