Basic Information
| Provider Information | |||||||||
| NPI: | 1740935220 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | BETHAN | ||||||||
| MiddleName: | ANNE | ||||||||
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| Credential: | HIS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 RILEY ST | ||||||||
| Address2: | |||||||||
| City: | GADSDEN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 359015432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2564891236 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2030 CECIL ASHBURN DR SE STE 100A | ||||||||
| Address2: | |||||||||
| City: | HUNTSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 358022578 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2564891236 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2022 | ||||||||
| LastUpdateDate: | 02/14/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237700000X | 2331 | AL | Y | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |
No ID Information.