Healthcare Provider Details

I. General information

NPI: 1619636974
Provider Name (Legal Business Name): CASEY WYLIE LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2021
Last Update Date: 12/14/2021
Certification Date: 12/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9957 MOORINGS DR STE 302
JACKSONVILLE FL
32257-2415
US

IV. Provider business mailing address

9957 MOORINGS DR STE 302
JACKSONVILLE FL
32257-2415
US

V. Phone/Fax

Practice location:
  • Phone: 888-793-2304
  • Fax: 888-793-2304
Mailing address:
  • Phone: 888-793-2304
  • Fax: 888-793-2304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: