Provider Demographics
NPI:1275171704
Name:WYLIE, LEAH CHRISTINE (DPT)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:CHRISTINE
Last Name:WYLIE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1275 17TH AVE APT 6
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94122-1928
Mailing Address - Country:US
Mailing Address - Phone:719-930-6255
Mailing Address - Fax:
Practice Address - Street 1:2655 BUSH ST STE C-1
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94115-3048
Practice Address - Country:US
Practice Address - Phone:415-353-7596
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-16
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT297199225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist