Healthcare Provider Details

I. General information

NPI: 1023638640
Provider Name (Legal Business Name): HOLLY MICHELLE WYLIE LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2020
Last Update Date: 04/23/2020
Certification Date: 04/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6262 LEAWOOD DR
HUBER HEIGHTS OH
45424-3039
US

IV. Provider business mailing address

6262 LEAWOOD DR
HUBER HEIGHTS OH
45424-3039
US

V. Phone/Fax

Practice location:
  • Phone: 938-367-5812
  • Fax:
Mailing address:
  • Phone: 938-367-5812
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number33.020556
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: