Basic Information
| Provider Information | |||||||||
| NPI: | 1821436536 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILDEY | ||||||||
| FirstName: | TRACI | ||||||||
| MiddleName: | JANELLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1020 W ARDMORE AVE | ||||||||
| Address2: | APT. 304 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606603700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8669910900 | ||||||||
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| Practice Location | |||||||||
| Address1: | 27240 HAGGERTY RD | ||||||||
| Address2: | SUITE E15 | ||||||||
| City: | FARMINGTON HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483315716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8669910900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2013 | ||||||||
| LastUpdateDate: | 06/05/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 146.011521 | IL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.