Healthcare Provider Details

I. General information

NPI: 1932315066
Provider Name (Legal Business Name): PATRICIA DIANE WYLLIE QMHP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 W B ST STE I
SPRINGFIELD OR
97477-4575
US

IV. Provider business mailing address

2060 EMERALD ST
EUGENE OR
97403-1525
US

V. Phone/Fax

Practice location:
  • Phone: 541-988-1025
  • Fax:
Mailing address:
  • Phone: 541-228-6778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: