Provider Demographics
NPI:1568796969
Name:WYLIE CENTER
Entity Type:Organization
Organization Name:WYLIE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:G
Authorized Official - Last Name:LILLO
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:951-683-5193
Mailing Address - Street 1:22964 PABLO
Mailing Address - Street 2:
Mailing Address - City:NUEVO
Mailing Address - State:CA
Mailing Address - Zip Code:92567-9635
Mailing Address - Country:US
Mailing Address - Phone:909-286-2184
Mailing Address - Fax:
Practice Address - Street 1:22964 PABLO
Practice Address - Street 2:
Practice Address - City:NUEVO
Practice Address - State:CA
Practice Address - Zip Code:92567-9635
Practice Address - Country:US
Practice Address - Phone:909-286-2184
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-01
Last Update Date:2009-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25834251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health