Provider Demographics
NPI:1518123157
Name:WYLIE, DONALD ALFRED II (COTA/L)
Entity Type:Individual
Prefix:MR
First Name:DONALD
Middle Name:ALFRED
Last Name:WYLIE
Suffix:II
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:278 DRY VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38506-5461
Mailing Address - Country:US
Mailing Address - Phone:931-537-6524
Mailing Address - Fax:
Practice Address - Street 1:278 DRY VALLEY RD
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38506-5461
Practice Address - Country:US
Practice Address - Phone:931-537-6524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-04
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0758224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant