Healthcare Provider Details

I. General information

NPI: 1417353616
Provider Name (Legal Business Name): SAMANTHA WYLLIE MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2014
Last Update Date: 03/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2775 TAPO ST SUITE 204
SIMI VALLEY CA
93063-0466
US

IV. Provider business mailing address

6341 PACIFIC RIDGE RD
SIMI VALLEY CA
93063-4772
US

V. Phone/Fax

Practice location:
  • Phone: 805-231-1094
  • Fax:
Mailing address:
  • Phone: 805-231-1094
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number83670
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: