Healthcare Provider Details

I. General information

NPI: 1669082590
Provider Name (Legal Business Name): WYLIE CENTER - A PSYCHOLOGICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2020
Last Update Date: 08/05/2020
Certification Date: 08/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4164 BROCKTON AVE
RIVERSIDE CA
92501-3400
US

IV. Provider business mailing address

4164 BROCKTON AVE
RIVERSIDE CA
92501-3400
US

V. Phone/Fax

Practice location:
  • Phone: 951-683-5193
  • Fax: 951-683-6019
Mailing address:
  • Phone: 951-683-5193
  • Fax: 951-683-6019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: MR. MICKEY RUBINSON
Title or Position: CEO
Credential:
Phone: 951-683-5193