Provider Demographics
NPI:1205962412
Name:WILDER, MARTHA J (MA, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:J
Last Name:WILDER
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1517 GREENPLAIN RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:SC
Mailing Address - Zip Code:29325-6809
Mailing Address - Country:US
Mailing Address - Phone:864-833-3933
Mailing Address - Fax:
Practice Address - Street 1:1517 GREENPLAIN RD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:SC
Practice Address - Zip Code:29325-6809
Practice Address - Country:US
Practice Address - Phone:864-833-3933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-24
Last Update Date:2010-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC467235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSA0036Medicaid