Provider Demographics
NPI:1285038018
Name:WYLIE, GRANT J
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:J
Last Name:WYLIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-3830
Mailing Address - Country:US
Mailing Address - Phone:360-425-8679
Mailing Address - Fax:
Practice Address - Street 1:1105 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-3830
Practice Address - Country:US
Practice Address - Phone:360-425-8679
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-22
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health