Healthcare Provider Details

I. General information

NPI: 1700890571
Provider Name (Legal Business Name): SCOTT A. WYLIE PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 12/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 ABRAHAM FLEXNER WAY
LOUISVILLE KY
40202
US

IV. Provider business mailing address

PO BOX 909
LOUISVILLE KY
40201-0909
US

V. Phone/Fax

Practice location:
  • Phone: 502-899-3626
  • Fax: 502-899-7970
Mailing address:
  • Phone: 502-588-0325
  • Fax: 502-588-0326

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number0810003670
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810003670
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPHD3062
License Number StateTN
# 4
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number173223
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: