Healthcare Provider Details

I. General information

NPI: 1972242857
Provider Name (Legal Business Name): KRISTIN WYLIE MS, CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2022
Last Update Date: 05/31/2022
Certification Date: 05/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3737 FENTON AVE
FORT WORTH TX
76133-2915
US

IV. Provider business mailing address

3737 FENTON AVE
FORT WORTH TX
76133-2915
US

V. Phone/Fax

Practice location:
  • Phone: 817-905-6874
  • Fax:
Mailing address:
  • Phone: 817-905-6874
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: