Healthcare Provider Details

I. General information

NPI: 1538752159
Provider Name (Legal Business Name): ELIZABETH T WYLDE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2021
Last Update Date: 04/16/2025
Certification Date: 04/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13 N WASHINGTON ST
YPSILANTI MI
48197-2617
US

IV. Provider business mailing address

801 W BIG BEAVER RD STE 300
TROY MI
48084-4725
US

V. Phone/Fax

Practice location:
  • Phone: 734-325-9531
  • Fax:
Mailing address:
  • Phone: 734-325-9531
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801109058
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: