Provider Demographics
NPI:1326590274
Name:WYSOGLAD, CAITLYN MARIE
Entity Type:Individual
Prefix:
First Name:CAITLYN
Middle Name:MARIE
Last Name:WYSOGLAD
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 1:920 W PRAIRIE DR
Mailing Address - Street 2:
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-3123
Mailing Address - Country:US
Mailing Address - Phone:920-206-4505
Mailing Address - Fax:
Practice Address - Street 1:920 W PRAIRIE DR
Practice Address - Street 2:
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-3123
Practice Address - Country:US
Practice Address - Phone:920-206-4505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-26
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1-18-31364103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst