Healthcare Provider Details

I. General information

NPI: 1730854175
Provider Name (Legal Business Name): KRISTIE WYLER MA, LLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2021
Last Update Date: 08/16/2022
Certification Date: 08/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

409 PLYMOUTH RD STE 250
PLYMOUTH MI
48170-1842
US

IV. Provider business mailing address

409 PLYMOUTH RD STE 250
PLYMOUTH MI
48170-1842
US

V. Phone/Fax

Practice location:
  • Phone: 734-416-9098
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6361007728
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: