Healthcare Provider Details

I. General information

NPI: 1609292275
Provider Name (Legal Business Name): DANA WYLIE CMT, CLT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2014
Last Update Date: 05/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

317 N EL CAMINO REAL STE 408
ENCINITAS CA
92024-2811
US

IV. Provider business mailing address

5423 LAKE MURRAY BLVD #9
LA MESA CA
91942-1548
US

V. Phone/Fax

Practice location:
  • Phone: 858-888-3756
  • Fax:
Mailing address:
  • Phone: 858-888-3756
  • Fax: 858-408-9404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number29684
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: