Provider Demographics
NPI:1730469222
Name:WILDE, LAURA E (SLP)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:E
Last Name:WILDE
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3030 S JONES BLVD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146-6792
Mailing Address - Country:US
Mailing Address - Phone:702-360-1137
Mailing Address - Fax:702-240-1729
Practice Address - Street 1:3030 S JONES BLVD
Practice Address - Street 2:SUITE 105
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-6792
Practice Address - Country:US
Practice Address - Phone:702-360-1137
Practice Address - Fax:702-240-1729
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-28
Last Update Date:2011-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1279235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist