Provider Demographics
NPI:1104834357
Name:WYLIE, DONNA LYNN (MA LMFT)
Entity Type:Individual
Prefix:MRS
First Name:DONNA
Middle Name:LYNN
Last Name:WYLIE
Suffix:
Gender:F
Credentials:MA LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:32605 HWY 79 SOUTH
Mailing Address - Street 2:SUITE 219
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92592
Mailing Address - Country:US
Mailing Address - Phone:951-506-9112
Mailing Address - Fax:951-506-9113
Practice Address - Street 1:32605 HWY 79 SOUTH
Practice Address - Street 2:SUITE 219
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92592
Practice Address - Country:US
Practice Address - Phone:951-506-9112
Practice Address - Fax:951-506-9113
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT36699106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist