Provider Demographics
NPI:1104356443
Name:WYLIE, LAURIE (EDS)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:
Last Name:WYLIE
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 TWIN OAKS CT
Mailing Address - Street 2:
Mailing Address - City:FORTSON
Mailing Address - State:GA
Mailing Address - Zip Code:31808-4479
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:107 TWIN OAKS CT
Practice Address - Street 2:
Practice Address - City:FORTSON
Practice Address - State:GA
Practice Address - Zip Code:31808-4479
Practice Address - Country:US
Practice Address - Phone:706-575-0924
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-19
Last Update Date:2017-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool