Basic Information
| Provider Information | |||||||||
| NPI: | 1871899500 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | LINDSAY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1365 GATEWAY TRL | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468455502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604175052 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4180 SAGE BLUFF XING | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468042363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604437300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2011 | ||||||||
| LastUpdateDate: | 08/19/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 46001961A | IN | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.