Healthcare Provider Details

I. General information

NPI: 1134345424
Provider Name (Legal Business Name): MR. JUSTIN JAY WYLIE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3274 ROSECRANS ST
SAN DIEGO CA
92110-4836
US

IV. Provider business mailing address

3274 ROSECRANS ST
SAN DIEGO CA
92110-4836
US

V. Phone/Fax

Practice location:
  • Phone: 619-226-2663
  • Fax: 619-226-2837
Mailing address:
  • Phone: 619-226-2663
  • Fax: 619-226-2837

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: