Provider Demographics
NPI:1962985184
Name:WILSON, HEATHER CAROL (CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:CAROL
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 1:259 WATROUS ROAD
Mailing Address - Street 2:
Mailing Address - City:RUPERT
Mailing Address - State:VT
Mailing Address - Zip Code:05776
Mailing Address - Country:US
Mailing Address - Phone:802-558-8165
Mailing Address - Fax:
Practice Address - Street 1:19 ROBINSON RD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NY
Practice Address - Zip Code:13323-1418
Practice Address - Country:US
Practice Address - Phone:315-853-6090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-13
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028041-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist