Provider Demographics
NPI:1306412689
Name:AYCOCK, WYLENE MICHELLE
Entity Type:Individual
Prefix:
First Name:WYLENE
Middle Name:MICHELLE
Last Name:AYCOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7505 WATERS AVE STE C6
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-3820
Mailing Address - Country:US
Mailing Address - Phone:912-398-4164
Mailing Address - Fax:
Practice Address - Street 1:7505 WATERS AVE STE C6
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-3820
Practice Address - Country:US
Practice Address - Phone:912-398-4164
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-27
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor