Provider Demographics
NPI:1861718033
Name:WILDER, LARISA M (CCC-SLP)
Entity type:Individual
Prefix:
First Name:LARISA
Middle Name:M
Last Name:WILDER
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3825 MONTEREY PL
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-1516
Mailing Address - Country:US
Mailing Address - Phone:720-536-8948
Mailing Address - Fax:720-536-8948
Practice Address - Street 1:3825 MONTEREY PLACE
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301
Practice Address - Country:US
Practice Address - Phone:720-536-8948
Practice Address - Fax:720-536-8948
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-13
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ12119008235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist