Healthcare Provider Details

I. General information

NPI: 1639856446
Provider Name (Legal Business Name): KIMBERLY SUE WILDGOR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2023
Last Update Date: 07/03/2023
Certification Date: 07/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

837 W CHRISTOPHER ST STE B
WEST COVINA CA
91790-3761
US

IV. Provider business mailing address

837 W CHRISTOPHER ST STE B
WEST COVINA CA
91790-3761
US

V. Phone/Fax

Practice location:
  • Phone: 626-856-1601
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number17859
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: