=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386462562
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FRANKLIN WYLIE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/27/2024
-----------------------------------------------------
Last Update Date | 09/27/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | (TELEHEALTH ONLY) 219 FOLSOM DR
-----------------------------------------------------
City | DAYTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45405-1111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-630-2045
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 219 FOLSOM DR
-----------------------------------------------------
City | DAYTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45405-1111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-630-2045
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. FRANKLIN D WYLIE JR.
-----------------------------------------------------
Credential | LICDC-CS, ICCS
-----------------------------------------------------
Telephone | 859-630-2045
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------