Healthcare Provider Details

I. General information

NPI: 1073390548
Provider Name (Legal Business Name): CAITLIN ALEXANDRA WYLIE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2023
Last Update Date: 09/11/2023
Certification Date: 09/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4240 SOUTHWEST BLVD
SAN ANGELO TX
76904-5634
US

IV. Provider business mailing address

2743 HARVARD AVE
SAN ANGELO TX
76904-5313
US

V. Phone/Fax

Practice location:
  • Phone: 432-263-7361
  • Fax:
Mailing address:
  • Phone: 325-657-8263
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number67882
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: