Healthcare Provider Details

I. General information

NPI: 1275186983
Provider Name (Legal Business Name): STACY ANNE WYLLIE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2019
Last Update Date: 05/23/2025
Certification Date: 05/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 ALBERT ST
MANDEVILLE LA
70448-5402
US

IV. Provider business mailing address

540 ALBERT ST
MANDEVILLE LA
70448-5402
US

V. Phone/Fax

Practice location:
  • Phone: 985-373-6423
  • Fax:
Mailing address:
  • Phone: 985-373-6423
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFT1581
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: