Provider Demographics
NPI:1194556894
Name:WILDERS, CARLIE MADISON (MA, SLP)
Entity type:Individual
Prefix:
First Name:CARLIE
Middle Name:MADISON
Last Name:WILDERS
Suffix:
Gender:F
Credentials:MA, SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2643 SWEET CLOVER CT
Mailing Address - Street 2:
Mailing Address - City:MINDEN
Mailing Address - State:NV
Mailing Address - Zip Code:89423-8887
Mailing Address - Country:US
Mailing Address - Phone:760-914-2252
Mailing Address - Fax:
Practice Address - Street 1:3310 GONI RD BLDG H
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89706-7917
Practice Address - Country:US
Practice Address - Phone:775-687-4210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-13
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVSP-3995235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist