Provider Demographics
NPI:1093359804
Name:WYLIE, CASSANDRA (LISW)
Entity Type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:
Last Name:WYLIE
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10792 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEW MIDDLETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44442-7729
Mailing Address - Country:US
Mailing Address - Phone:330-774-6288
Mailing Address - Fax:
Practice Address - Street 1:45875 BELL SCHOOL RD STE B
Practice Address - Street 2:
Practice Address - City:EAST LIVERPOOL
Practice Address - State:OH
Practice Address - Zip Code:43920-8728
Practice Address - Country:US
Practice Address - Phone:330-397-6007
Practice Address - Fax:234-254-5655
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-05
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.2103168-SUPV1041C0700X
OHS1600867104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker