Healthcare Provider Details

I. General information

NPI: 1568796969
Provider Name (Legal Business Name): WYLIE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2009
Last Update Date: 10/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22964 PABLO
NUEVO CA
92567-9635
US

IV. Provider business mailing address

22964 PABLO
NUEVO CA
92567-9635
US

V. Phone/Fax

Practice location:
  • Phone: 909-286-2184
  • Fax:
Mailing address:
  • Phone: 909-286-2184
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number25834
License Number StateCA

VIII. Authorized Official

Name: MS. SAMANTHA G. LILLO
Title or Position: SUPERVISOR
Credential: LCSW
Phone: 951-683-5193