Provider Demographics
NPI:1174985089
Name:WILES, BRENT LEWIS (MS, CCC-SLP)
Entity type:Individual
Prefix:MR
First Name:BRENT
Middle Name:LEWIS
Last Name:WILES
Suffix:
Gender:M
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 40480
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36640-0480
Mailing Address - Country:US
Mailing Address - Phone:251-434-3626
Mailing Address - Fax:251-445-2464
Practice Address - Street 1:5721 USA DRIVE N
Practice Address - Street 2:HAHN1119
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36608-0002
Practice Address - Country:US
Practice Address - Phone:251-445-9378
Practice Address - Fax:251-445-9377
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-22
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3665235Z00000X
FLSA12185235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist