Healthcare Provider Details

I. General information

NPI: 1942251939
Provider Name (Legal Business Name): GARY THOMAS WYLIN L.C.S.W.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2006
Last Update Date: 07/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 N HEPBURN AVE SUITE 203
JUPITER FL
33458-5015
US

IV. Provider business mailing address

609 N HEPBURN AVE SUITE 203
JUPITER FL
33458-5015
US

V. Phone/Fax

Practice location:
  • Phone: 561-743-1408
  • Fax: 561-743-1403
Mailing address:
  • Phone: 561-743-1408
  • Fax: 561-743-1403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW2131
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: