Provider Demographics
NPI:1568556033
Name:WILDERMUTH, DAWN (MS CCC/SLP)
Entity Type:Individual
Prefix:
First Name:DAWN
Middle Name:
Last Name:WILDERMUTH
Suffix:
Gender:F
Credentials:MS CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1210 LEXINGTON DR.
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34292
Mailing Address - Country:US
Mailing Address - Phone:941-468-6701
Mailing Address - Fax:
Practice Address - Street 1:2574 COMMERCE PKWY
Practice Address - Street 2:
Practice Address - City:NORTH PORT
Practice Address - State:FL
Practice Address - Zip Code:34289-9334
Practice Address - Country:US
Practice Address - Phone:941-485-0121
Practice Address - Fax:941-485-0591
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA0000934235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist