Provider Demographics
NPI:1497881122
Name:WILDS, DONNA D (SLP)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:D
Last Name:WILDS
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3760 LAVISTA RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-5615
Mailing Address - Country:US
Mailing Address - Phone:404-284-0415
Mailing Address - Fax:404-248-0422
Practice Address - Street 1:3760 LAVISTA RD
Practice Address - Street 2:SUITE 102
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-5615
Practice Address - Country:US
Practice Address - Phone:404-284-0415
Practice Address - Fax:404-248-0422
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP003833235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist