Provider Demographics
NPI:1396812376
Name:WILDE, GRAHAM LEONARD (PHD)
Entity type:Individual
Prefix:DR
First Name:GRAHAM
Middle Name:LEONARD
Last Name:WILDE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5315B SUNSET BLVD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072-9159
Mailing Address - Country:US
Mailing Address - Phone:803-808-9611
Mailing Address - Fax:803-808-6848
Practice Address - Street 1:5315B SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-9159
Practice Address - Country:US
Practice Address - Phone:803-808-9611
Practice Address - Fax:803-808-6848
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC249231H00000X
GAAUD000296231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAAUD000296OtherSTATE AUDIOLOGY LICENSE
SCSA0007Medicaid
SC249OtherSTATE AUDIOLOGY LICENSE