Healthcare Provider Details

I. General information

NPI: 1295278810
Provider Name (Legal Business Name): SAMANTHA WYLIE LMFTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2016
Last Update Date: 12/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3220 TRIMBLESTONE LN APT 302
RALEIGH NC
27616-5931
US

IV. Provider business mailing address

3220 TRIMBLESTONE LN APT 302
RALEIGH NC
27616-5931
US

V. Phone/Fax

Practice location:
  • Phone: 248-990-6153
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number12010A
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: