Provider Demographics
NPI:1174877682
Name:WILBANKS, DEECIE MANN (MSP, CCC-SLP)
Entity type:Individual
Prefix:
First Name:DEECIE
Middle Name:MANN
Last Name:WILBANKS
Suffix:
Gender:F
Credentials:MSP, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416 LAKE FOREST DR
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-3373
Mailing Address - Country:US
Mailing Address - Phone:803-360-4589
Mailing Address - Fax:
Practice Address - Street 1:416 LAKE FOREST DR
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-3373
Practice Address - Country:US
Practice Address - Phone:803-360-4589
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-06
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP008038235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist