Healthcare Provider Details

I. General information

NPI: 1871477596
Provider Name (Legal Business Name): CHRISTOPHER WYLIE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2025
Last Update Date: 08/05/2025
Certification Date: 08/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1407 W MCMILLAN RD STE 120
MERIDIAN ID
83646-5168
US

IV. Provider business mailing address

1775 W STATE ST # 371
BOISE ID
83702-3924
US

V. Phone/Fax

Practice location:
  • Phone: 208-315-6717
  • Fax: 208-315-6718
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: