Provider Demographics
NPI:1598189086
Name:WILDER LANGUAGE AND LEARNING
Entity Type:Organization
Organization Name:WILDER LANGUAGE AND LEARNING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ SPEECH LANGUAGE PATH
Authorized Official - Prefix:
Authorized Official - First Name:LARISA
Authorized Official - Middle Name:M
Authorized Official - Last Name:WILDER
Authorized Official - Suffix:
Authorized Official - Credentials:MA SLP/CCC
Authorized Official - Phone:303-818-0508
Mailing Address - Street 1:3825 MONTEREY PLACE
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3825 MONTEREY PLACE
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301
Practice Address - Country:US
Practice Address - Phone:303-818-0508
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-05
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO12119008235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1861718033Medicaid
AZ1861718033Medicaid