Provider Demographics
NPI:1497389183
Name:WYLIE, LYDIA ANN (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:ANN
Last Name:WYLIE
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2629 N HAMPDEN CT APT 407
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-1747
Mailing Address - Country:US
Mailing Address - Phone:563-590-3420
Mailing Address - Fax:
Practice Address - Street 1:10 N SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-3310
Practice Address - Country:US
Practice Address - Phone:847-825-1161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-03
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146014721235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist