Basic Information
| Provider Information | |||||||||
| NPI: | 1891798419 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILDER | ||||||||
| FirstName: | KATHRYN | ||||||||
| MiddleName: | V | ||||||||
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| Credential: | AU.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3540 FOREST HILL BLVD | ||||||||
| Address2: | STE 205 | ||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334065878 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5616494006 | ||||||||
| FaxNumber: | 5619696621 | ||||||||
| Practice Location | |||||||||
| Address1: | 3540 FOREST HILL BLVD | ||||||||
| Address2: | STE 205 | ||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334065878 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5616494006 | ||||||||
| FaxNumber: | 5619696621 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2005 | ||||||||
| LastUpdateDate: | 02/26/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | AY338 | FL | Y | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 600035500 | 05 | FL | MEDICAID | 640001185 | 01 | FL | RAILROAD MEDICARE | OTHER | S1037 | 01 | FL | BCBS | OTHER | 600035507 | 05 | FL | MEDICAID | 600037100 | 05 | FL | MEDICAID | 600035508 | 05 | FL | MEDICAID |