Provider Demographics
NPI:1114266251
Name:WYLLIE, DEMARISH N (LCDC, CART)
Entity Type:Individual
Prefix:MR
First Name:DEMARISH
Middle Name:N
Last Name:WYLLIE
Suffix:
Gender:M
Credentials:LCDC, CART
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 SUGAR CREEK CENTER BLVD STE 600
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77478-3688
Mailing Address - Country:US
Mailing Address - Phone:832-441-5124
Mailing Address - Fax:
Practice Address - Street 1:77 SUGAR CREEK CENTER BLVD STE 600
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77478-3688
Practice Address - Country:US
Practice Address - Phone:832-441-5124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-09
Last Update Date:2021-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11963101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)