MEDICARE: DR. DERRICO WYLIE PHD, LCPC, NCC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor		MD

General Provider Information

NPI Number	:	1700914801
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DERRICO WYLIE PHD, LCPC, NCC

Provider Business Mailing Address
First Line	:	5713 LINDA LN
Second Line	:
City	:	CAMP SPRINGS
State	:	MD
Zip	:	20748-2331
Country	:	US
Telephone Number	:	615-300-7092
Fax Number	:

Provider Business Practice Location Address
First Line	:	5713 LINDA LN
Second Line	:
City	:	CAMP SPRINGS
State	:	MD
Zip	:	20748-2331
Country	:	US
Telephone Number	:	615-300-7092
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/01/2007
Last Update Date	:	11/17/2019

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