Healthcare Provider Details

I. General information

NPI: 1891237434
Provider Name (Legal Business Name): WYLIE & ASSOCIATES BEHAVIORAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2016
Last Update Date: 11/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 S SEMINARY ST
COLLINSVILLE IL
62234-2634
US

IV. Provider business mailing address

118 SEMINARY STREET
COLLINSVILLE IL
62234
US

V. Phone/Fax

Practice location:
  • Phone: 618-855-8815
  • Fax:
Mailing address:
  • Phone: 618-855-8815
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number209005228
License Number StateIL

VIII. Authorized Official

Name: MELANIE ANN WYLIE
Title or Position: APN MANAGER
Credential: RN MSN CNS APN
Phone: 618-593-0134