Provider Demographics
NPI:1962666735
Name:WILDER, NICHOLE DOREEN (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:NICHOLE
Middle Name:DOREEN
Last Name:WILDER
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:MRS
Other - First Name:NICHOLE
Other - Middle Name:DOREEN
Other - Last Name:ROBERTSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCC-SLP
Mailing Address - Street 1:2700 SIMPSON AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:WA
Mailing Address - Zip Code:98520-4333
Mailing Address - Country:US
Mailing Address - Phone:360-537-2743
Mailing Address - Fax:360-537-6812
Practice Address - Street 1:2700 SIMPSON AVE STE 201
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:WA
Practice Address - Zip Code:98520-4333
Practice Address - Country:US
Practice Address - Phone:360-537-2743
Practice Address - Fax:360-537-6812
Is Sole Proprietor?:No
Enumeration Date:2008-07-10
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL00004380235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist