| Doctor Name: | NICOLE S WILSON |
| NPI Number: | 1073833133 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | SLP |
| License Number: | 146005626 |
| Business Practice Address: | 201 Lafayette Ave Mattoon, IL - 619384409 |
| Business Phone Number: | 2172355449 |
| Business Fax Number: | 2172350611 |
| Mailing Address: | 550 Frontage Rd, Suite 2415 NORTHFIELD |
| State: | IL |
| Postal Code: | 600931202 |
| Phone Number: | 8474415593 |
| Fax Number: | 8474410734 |
| NPI Enumeration Date: | 06/10/2010 |
| NPI Last Update Date: | 06/10/2010 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 235Z00000X |
| License Number: | 146005626 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | IL |
| Taxonomy Type: | Speech, Language and Hearing Service Providers |
| Taxonomy Classification: | Speech-Language Pathologist |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A speech pathologist is a person qualified by a master |