Healthcare Provider Details

I. General information

NPI: 1740094416
Provider Name (Legal Business Name): AUSTIN WYLIE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2025
Last Update Date: 02/04/2025
Certification Date: 02/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2339 N CALIFORNIA AVE UNIT 47949
CHICAGO IL
60647-0360
US

IV. Provider business mailing address

2339 N CALIFORNIA AVE UNIT 47949
CHICAGO IL
60647-0360
US

V. Phone/Fax

Practice location:
  • Phone: 417-299-1462
  • Fax:
Mailing address:
  • Phone: 417-299-1462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number150.115735
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: