Healthcare Provider Details

I. General information

NPI: 1235451592
Provider Name (Legal Business Name): DWAN WIGGINS SLPA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2010
Last Update Date: 02/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6006 W. 158TH
OAK FORREST IL
60452
US

IV. Provider business mailing address

24306 S SHADY OAKS TRL
CRETE IL
60417-2726
US

V. Phone/Fax

Practice location:
  • Phone: 708-535-0933
  • Fax:
Mailing address:
  • Phone: 708-672-0954
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number217000162
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: