Provider Demographics
NPI:1609177179
Name:WYLIE, ROBERT WILLIAM (BC-HIS)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:WILLIAM
Last Name:WYLIE
Suffix:
Gender:M
Credentials:BC-HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1114 HICKORY DR
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:MS
Mailing Address - Zip Code:39560-3223
Mailing Address - Country:US
Mailing Address - Phone:228-863-8050
Mailing Address - Fax:228-863-1693
Practice Address - Street 1:100 LAROSA RD
Practice Address - Street 2:STE D
Practice Address - City:LONG BEACH
Practice Address - State:MS
Practice Address - Zip Code:39560
Practice Address - Country:US
Practice Address - Phone:228-863-8050
Practice Address - Fax:228-863-1693
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-15
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSHAD 0457237700000X
ALAL 4079237700000X
LA1080237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist