Provider Demographics
NPI:1336281104
Name:WILDE, ADRIENNE KATHERINE (MS, CCC SLP)
Entity Type:Individual
Prefix:MRS
First Name:ADRIENNE
Middle Name:KATHERINE
Last Name:WILDE
Suffix:
Gender:F
Credentials:MS, CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:5521 DOVE LAKE RD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65101-9328
Mailing Address - Country:US
Mailing Address - Phone:573-291-4646
Mailing Address - Fax:573-632-5990
Practice Address - Street 1:1432 SOUTHWEST BLVD
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-2444
Practice Address - Country:US
Practice Address - Phone:573-632-5633
Practice Address - Fax:537-632-5990
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO117608235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist