Provider Demographics
NPI:1326228974
Name:WILEY, VIRGINIA SMITH (CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:VIRGINIA
Middle Name:SMITH
Last Name:WILEY
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:MS
Other - First Name:VIRGINIA
Other - Middle Name:SMITH
Other - Last Name:WILEY-SYLVIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCC-SLP
Mailing Address - Street 1:4571 MILES DRIVE
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-9241
Mailing Address - Country:US
Mailing Address - Phone:772-559-2937
Mailing Address - Fax:386-261-8787
Practice Address - Street 1:1834 MASON AVE
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117
Practice Address - Country:US
Practice Address - Phone:772-559-2937
Practice Address - Fax:386-261-8787
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-13
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA4572235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist