Healthcare Provider Details

I. General information

NPI: 1013709633
Provider Name (Legal Business Name): ROBERT HEATH WYLIE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2025
Last Update Date: 05/20/2025
Certification Date: 05/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7545 AIRWAYS BLVD
SOUTHAVEN MS
38671-5806
US

IV. Provider business mailing address

7545 AIRWAYS BLVD
SOUTHAVEN MS
38671-5806
US

V. Phone/Fax

Practice location:
  • Phone: 901-759-3208
  • Fax:
Mailing address:
  • Phone: 901-759-3208
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT6708
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: