Healthcare Provider Details

I. General information

NPI: 1801673769
Provider Name (Legal Business Name): KELLY DIANE WYLIE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2023
Last Update Date: 09/13/2023
Certification Date: 09/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

756 PURPLE SAGE RD
BANDERA TX
78003-3981
US

IV. Provider business mailing address

21300 STATE HIGHWAY 16 N UNIT 214
MEDINA TX
78055-3819
US

V. Phone/Fax

Practice location:
  • Phone: 830-225-1622
  • Fax:
Mailing address:
  • Phone: 830-398-0414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number64298
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: