Healthcare Provider Details

I. General information

NPI: 1497389183
Provider Name (Legal Business Name): LYDIA ANN WYLIE M.S., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2020
Last Update Date: 03/10/2020
Certification Date: 03/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 N SUMMIT AVE
PARK RIDGE IL
60068-3310
US

IV. Provider business mailing address

2629 N HAMPDEN CT APT 407
CHICAGO IL
60614-1747
US

V. Phone/Fax

Practice location:
  • Phone: 847-825-1161
  • Fax:
Mailing address:
  • Phone: 563-590-3420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number146014721
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: