Healthcare Provider Details

I. General information

NPI: 1063210011
Provider Name (Legal Business Name): CORI H WYLIE LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2025
Last Update Date: 03/05/2025
Certification Date: 03/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1104 N COLLEGE ST
HUNTSVILLE AR
72740-9672
US

IV. Provider business mailing address

1104 N COLLEGE ST
HUNTSVILLE AR
72740-9672
US

V. Phone/Fax

Practice location:
  • Phone: 479-728-2878
  • Fax:
Mailing address:
  • Phone: 479-728-2878
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: