| Doctor Name: | LARISA M WILDER |
| NPI Number: | 1861718033 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | CCC-SLP |
| License Number: | 12119008 |
| Business Practice Address: | 3825 Monterey Place Boulder, CO - 80301 |
| Business Phone Number: | 7205368948 |
| Business Fax Number: | 7205368948 |
| Mailing Address: | 3825 Monterey Pl, BOULDER |
| State: | CO |
| Postal Code: | 803011516 |
| Phone Number: | 7205368948 |
| Fax Number: | 7205368948 |
| NPI Enumeration Date: | 04/13/2010 |
| NPI Last Update Date: | 01/02/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 235Z00000X |
| License Number: | 12119008 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | AZ |
| Taxonomy Type: | Speech, Language and Hearing Service Providers |
| Taxonomy Classification: | Speech-Language Pathologist |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A speech pathologist is a person qualified by a master |