Provider Demographics
NPI:1558321125
Name:WIGGINS, SYLENA MOSELY (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SYLENA
Middle Name:MOSELY
Last Name:WIGGINS
Suffix:
Gender:F
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 1:100 SOUTH WEST STREET
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:39817
Mailing Address - Country:US
Mailing Address - Phone:229-248-2837
Mailing Address - Fax:229-248-2844
Practice Address - Street 1:100 SOUTH WEST STREET
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:39817
Practice Address - Country:US
Practice Address - Phone:229-248-2837
Practice Address - Fax:229-248-2844
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2014-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP005081235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA463964078AMedicaid