Basic Information
| Provider Information | |||||||||
| NPI: | 1275685687 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | MANDI | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.S., CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4414 W SAN CARLOS ST | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336295544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8136010497 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2401 E HENRY AVE | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336104434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139887633 | ||||||||
| FaxNumber: | 8132378593 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SA 6054 | FL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.