Healthcare Provider Details

I. General information

NPI: 1114266251
Provider Name (Legal Business Name): DEMARISH N WYLLIE LCDC, SAP, CART
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2013
Last Update Date: 06/13/2025
Certification Date: 06/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4603 JAYMAR DR
SUGAR LAND TX
77479-5228
US

IV. Provider business mailing address

4603 JAYMAR DR
SUGAR LAND TX
77479-5228
US

V. Phone/Fax

Practice location:
  • Phone: 832-441-5124
  • Fax:
Mailing address:
  • Phone: 832-441-5124
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number11963
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: