Provider Demographics
NPI:1134543622
Name:WILDER, TAHNEE LECLERC (MSSLP)
Entity type:Individual
Prefix:MRS
First Name:TAHNEE
Middle Name:LECLERC
Last Name:WILDER
Suffix:
Gender:F
Credentials:MSSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1850 LEE RD STE 134
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-2104
Mailing Address - Country:US
Mailing Address - Phone:407-485-3179
Mailing Address - Fax:
Practice Address - Street 1:1850 LEE RD STE 134
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-2104
Practice Address - Country:US
Practice Address - Phone:407-485-3179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-05
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ6580235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSZ6580OtherSTATE LICENSE