Provider Demographics
NPI:1053639088
Name:WYLIE, HART KATHERINE (PMHNP, LPC)
Entity Type:Individual
Prefix:
First Name:HART
Middle Name:KATHERINE
Last Name:WYLIE
Suffix:
Gender:F
Credentials:PMHNP, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1855 LAKELAND DR
Mailing Address - Street 2:SUITE P-121
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4913
Mailing Address - Country:US
Mailing Address - Phone:601-366-4696
Mailing Address - Fax:
Practice Address - Street 1:1855 LAKELAND DR
Practice Address - Street 2:SUITE P-121
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4913
Practice Address - Country:US
Practice Address - Phone:601-366-4696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-14
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1360101YP2500X
MST0434106H00000X
MSR883581363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist