Healthcare Provider Details

I. General information

NPI: 1336209774
Provider Name (Legal Business Name): THOMAS FREDERICK WYLIE PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11573 LOS OSOS VALLEY RD SUITE C
SAN LUIS OBISPO CA
93405-6473
US

IV. Provider business mailing address

11573 LOS OSOS VALLEY RD SUITE C
SAN LUIS OBISPO CA
93405-6473
US

V. Phone/Fax

Practice location:
  • Phone: 805-545-8951
  • Fax: 805-545-8951
Mailing address:
  • Phone: 805-545-8951
  • Fax: 805-545-8951

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY12486
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY12486
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: