=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609292275
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DANA WYLIE CMT, CLT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2014
-----------------------------------------------------
Last Update Date | 05/03/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 317 N EL CAMINO REAL STE 408
-----------------------------------------------------
City | ENCINITAS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92024-2811
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-888-3756
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5423 LAKE MURRAY BLVD #9
-----------------------------------------------------
City | LA MESA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91942-1548
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-888-3756
-----------------------------------------------------
Fax | 858-408-9404
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 29684
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------