Healthcare Provider Details

I. General information

NPI: 1811560089
Provider Name (Legal Business Name): WYLIE COMMUNITY COUNSELING - PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2021
Last Update Date: 07/23/2021
Certification Date: 06/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

VIRTUAL ONLY AT THIS TIME
WYLIE TX
75098
US

IV. Provider business mailing address

PO BOX 1566
WYLIE TX
75098-1566
US

V. Phone/Fax

Practice location:
  • Phone: 469-626-9600
  • Fax:
Mailing address:
  • Phone: 281-705-7839
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: BRYAN DAVID YOUNG
Title or Position: OWNER
Credential: LPC
Phone: 281-705-7839