Provider Demographics
NPI:1609292275
Name:WYLIE, DANA (CMT, CLT)
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:
Last Name:WYLIE
Suffix:
Gender:F
Credentials:CMT, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5423 LAKE MURRAY BLVD
Mailing Address - Street 2:#9
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-1548
Mailing Address - Country:US
Mailing Address - Phone:858-888-3756
Mailing Address - Fax:858-408-9404
Practice Address - Street 1:317 N EL CAMINO REAL
Practice Address - Street 2:STE 408
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-2811
Practice Address - Country:US
Practice Address - Phone:858-888-3756
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-06
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29684225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist