Provider Demographics
NPI:1255663217
Name:WYTHE, JULIE A (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:A
Last Name:WYTHE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9260 E SCOTT RD
Mailing Address - Street 2:
Mailing Address - City:STILLMAN VALLEY
Mailing Address - State:IL
Mailing Address - Zip Code:61084-9767
Mailing Address - Country:US
Mailing Address - Phone:815-988-7039
Mailing Address - Fax:
Practice Address - Street 1:412 W WASHINGTON ST STE 6
Practice Address - Street 2:
Practice Address - City:OREGON
Practice Address - State:IL
Practice Address - Zip Code:61061-1623
Practice Address - Country:US
Practice Address - Phone:815-988-9899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-02
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0116221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical