1720502909 NPI number — TRINA RENEE WILSON SPEECH LANGUAGE PATH

Table of content: TRINA RENEE WILSON SPEECH LANGUAGE PATH (NPI 1720502909)

General
Organization/Personal Information
Provider's Other Name Information
NPI Number Information
Provider's Business Mailing Address
Provider's Practice Location Mailing Address
Additional Information
Authorized Official
Provider Taxonomy Codes
Other Provider's Identifiers (legacy, non-NPI)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720502909 NPI number — TRINA RENEE WILSON SPEECH LANGUAGE PATH

Organization/Personal Information

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:
WILSON

Provider First Name:
TRINA

Provider Middle Name:
RENEE

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:
SPEECH LANGUAGE PATH

Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:
BRANCH

Provider Other First Name:
TRINA

Provider Other Middle Name:
RENEE

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:
SPEECH LANGUAGE PATH

Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1720502909

Entity Type Code:
Individual

Replacement NPI:

Last Update Date:
07/31/2017

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1271 NE HIGHWAY 99W # 124

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:
MCMINNVILLE

Provider Business Mailing Address State Name:
OR

Provider Business Mailing Address Postal Code:
97128-2720

Provider Business Mailing Address Country Code:
US

Provider Business Mailing Address Telephone Number:
509-868-8944

Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
201 SE TIDE AVE

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:
LINCOLN CITY

Provider Business Practice Location Address State Name:
OR

Provider Business Practice Location Address Postal Code:
97367-3058

Provider Business Practice Location Address Country Code:
US

Provider Business Practice Location Address Telephone Number:
509-868-8944

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:
07/31/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

Provider Taxonomy Codes

Taxonomy code: 235Z00000X , with the licence number: 12754 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .