Healthcare Provider Details

I. General information

NPI: 1811505548
Provider Name (Legal Business Name): JEFFREY THOMAS WYLIE LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2020
Last Update Date: 11/07/2023
Certification Date: 11/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2204 KENTUCKY AVE
PADUCAH KY
42003-3242
US

IV. Provider business mailing address

121 BYRON DR
PADUCAH KY
42003-0963
US

V. Phone/Fax

Practice location:
  • Phone: 270-777-4490
  • Fax: 866-441-1083
Mailing address:
  • Phone: 270-556-8715
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number922
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: