Healthcare Provider Details

I. General information

NPI: 1255663217
Provider Name (Legal Business Name): JULIE A WYTHE L.C.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2010
Last Update Date: 02/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 W WASHINGTON ST STE 6
OREGON IL
61061-1623
US

IV. Provider business mailing address

9260 E SCOTT RD
STILLMAN VALLEY IL
61084-9767
US

V. Phone/Fax

Practice location:
  • Phone: 815-988-9899
  • Fax:
Mailing address:
  • Phone: 815-988-7039
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.011622
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: