Basic Information
Provider Information | |||||||||
NPI: | 1770643793 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROBERTS | ||||||||
FirstName: | WILDER | ||||||||
MiddleName: | MAYHALL | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | AUD, CCC-A | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MAYHALL | ||||||||
OtherFirstName: | JULIA | ||||||||
OtherMiddleName: | WILDER | ||||||||
OtherNamePrefix: | MRS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | AUD, CCC-A | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 40277 | ||||||||
Address2: |   | ||||||||
City: | MOBILE | ||||||||
State: | AL | ||||||||
PostalCode: | 366400277 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2514459378 | ||||||||
FaxNumber: | 2514459377 | ||||||||
Practice Location | |||||||||
Address1: | 5271 USA DR N | ||||||||
Address2: | HAHN 1119 | ||||||||
City: | MOBILE | ||||||||
State: | AL | ||||||||
PostalCode: | 366880002 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2514459378 | ||||||||
FaxNumber: | 2514459377 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/11/2006 | ||||||||
LastUpdateDate: | 07/21/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 805A | AL | Y |   | Speech, Language and Hearing Service Providers | Audiologist |   |
No ID Information.