Provider Demographics
NPI:1821436536
Name:WILDEY, TRACI JANELLE
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:JANELLE
Last Name:WILDEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 W ARDMORE AVE
Mailing Address - Street 2:APT. 304
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60660-3700
Mailing Address - Country:US
Mailing Address - Phone:866-991-0900
Mailing Address - Fax:
Practice Address - Street 1:27240 HAGGERTY RD
Practice Address - Street 2:SUITE E15
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48331-5716
Practice Address - Country:US
Practice Address - Phone:866-991-0900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-05
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.011521235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist