Healthcare Provider Details

I. General information

NPI: 1326590274
Provider Name (Legal Business Name): CAITLYN MARIE WYSOGLAD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2016
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

89 BOULDER HILL PASS
MONTGOMERY IL
60538-1911
US

IV. Provider business mailing address

89 BOULDER HILL PASS
MONTGOMERY IL
60538-1911
US

V. Phone/Fax

Practice location:
  • Phone: 630-331-3667
  • Fax:
Mailing address:
  • Phone: 630-331-3667
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-18-31364
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: