Healthcare Provider Details

I. General information

NPI: 1003174236
Provider Name (Legal Business Name): TOMMI ANN WILDE SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2012
Last Update Date: 04/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 CHARLEVOIX DR SE SUITE 200
GRAND RAPIDS MI
49546-7085
US

IV. Provider business mailing address

23 PIED CT
ORLANDO FL
32828-7132
US

V. Phone/Fax

Practice location:
  • Phone: 800-684-8049
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA8222
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: