Brandon R Wigboldy, MS CCC-SLP/L

Primary specialty

Speech-Language PathologistTaxonomy code 235Z00000X

License

146011666 Issued in IL

Practice address

17207 71St Ave
Tinley Park, IL 60477-3303

Phone

(708) 362-4603

NPI assigned

Dec 9, 2016

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

Credentials

Master of Science

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1481241600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1481241600000",
    "number": "1285178277",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "17207 71ST AVE",
            "city": "TINLEY PARK",
            "state": "IL",
            "postal_code": "604773303",
            "telephone_number": "708-362-4603"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "17207 71ST AVE",
            "city": "TINLEY PARK",
            "state": "IL",
            "postal_code": "604773303",
            "telephone_number": "708-362-4603"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WIGBOLDY",
        "first_name": "BRANDON",
        "middle_name": "R",
        "credential": "MS CCC-SLP/L",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2016-12-09",
        "last_updated": "2016-12-09",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "235Z00000X",
            "taxonomy_group": "",
            "desc": "Speech-Language Pathologist",
            "state": "IL",
            "license": "146011666",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Speech-Language Pathologist in Tinley Park, IL
• Providers in Tinley Park, IL by specialty
• Speech-Language Pathologist in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 9, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.