Healthcare Provider Details

I. General information

NPI: 1588253694
Provider Name (Legal Business Name): KATRINA WYLIE RBT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2021
Last Update Date: 09/16/2025
Certification Date: 09/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14765 W MOUNTAIN VIEW BLVD
SURPRISE AZ
85374-2704
US

IV. Provider business mailing address

14765 W MOUNTAIN VIEW BLVD
SURPRISE AZ
85374-2704
US

V. Phone/Fax

Practice location:
  • Phone: 602-649-0245
  • Fax: 602-926-2561
Mailing address:
  • Phone: 602-649-0245
  • Fax: 602-926-2561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-21-151524
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: