Provider Demographics
NPI:1992964019
Name:WILSON, MARY M (MA, CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:M
Last Name:WILSON
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Gender:F
Credentials:MA, CCC-SLP
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Mailing Address - Street 1:9040 EXECUTIVE PARK DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37923-4640
Mailing Address - Country:US
Mailing Address - Phone:865-603-5680
Mailing Address - Fax:865-769-0801
Practice Address - Street 1:9040 EXECUTIVE PARK DR
Practice Address - Street 2:SUITE 102
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923-4640
Practice Address - Country:US
Practice Address - Phone:865-693-5622
Practice Address - Fax:865-769-0801
Is Sole Proprietor?:No
Enumeration Date:2008-06-04
Last Update Date:2008-06-04
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TNSP0000002937235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist