Provider Demographics
NPI:1164825121
Name:WILDE, DEVLIN (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:DEVLIN
Middle Name:
Last Name:WILDE
Suffix:
Gender:M
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:557 CEDAR CREEK FARM RD
Mailing Address - Street 2:
Mailing Address - City:TUCKASEGEE
Mailing Address - State:NC
Mailing Address - Zip Code:28783-9677
Mailing Address - Country:US
Mailing Address - Phone:828-554-5105
Mailing Address - Fax:
Practice Address - Street 1:557 CEDAR CREEK FARM RD
Practice Address - Street 2:
Practice Address - City:TUCKASEGEE
Practice Address - State:NC
Practice Address - Zip Code:28783-9677
Practice Address - Country:US
Practice Address - Phone:828-554-5105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-06
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9692235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist