Provider Demographics
NPI:1699431064
Name:WILSON, SHILOH (CCC-SLP)
Entity type:Individual
Prefix:
First Name:SHILOH
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 W SURF ST APT 2R
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-9815
Mailing Address - Country:US
Mailing Address - Phone:660-349-0785
Mailing Address - Fax:
Practice Address - Street 1:1715 W LAKE ST
Practice Address - Street 2:
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160-3818
Practice Address - Country:US
Practice Address - Phone:660-349-0785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-10
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61137101235Z00000X
IL146.016650235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist