1962666735 NPI number — MRS. NICHOLE DOREEN WILDER M.S., CCC-SLP

Table of content: MRS. NICHOLE DOREEN WILDER M.S., CCC-SLP (NPI 1962666735)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962666735 NPI number — MRS. NICHOLE DOREEN WILDER M.S., CCC-SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILDER
Provider First Name:
NICHOLE
Provider Middle Name:
DOREEN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
M.S., CCC-SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ROBERTSON
Provider Other First Name:
NICHOLE
Provider Other Middle Name:
DOREEN
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MS CCC-SLP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1962666735
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/25/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2700 SIMPSON AVE STE 201
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ABERDEEN
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98520-4333
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-537-2743
Provider Business Mailing Address Fax Number:
360-537-6812

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2700 SIMPSON AVE STE 201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ABERDEEN
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98520-4333
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-537-2743
Provider Business Practice Location Address Fax Number:
360-537-6812
Provider Enumeration Date:
07/10/2008

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:  LL00004380 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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