Healthcare Provider Details

I. General information

NPI: 1013554492
Provider Name (Legal Business Name): JEREMIAH TYLER WYLIE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2019
Last Update Date: 05/23/2025
Certification Date: 05/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2141 PALOMAR AIRPORT RD STE 350
CARLSBAD CA
92011-1451
US

IV. Provider business mailing address

9406 PENNYWOOD RD
SANTEE CA
92071-1312
US

V. Phone/Fax

Practice location:
  • Phone: 760-710-2460
  • Fax:
Mailing address:
  • Phone: 619-701-1610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: