Provider Demographics
NPI:1629231840
Name:WYLIE, CAROL RUCH (CCC/SLP)
Entity Type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:RUCH
Last Name:WYLIE
Suffix:
Gender:F
Credentials:CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 ILLINI DR
Mailing Address - Street 2:
Mailing Address - City:EAST PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61611-1840
Mailing Address - Country:US
Mailing Address - Phone:309-694-6446
Mailing Address - Fax:309-698-0650
Practice Address - Street 1:901 ILLINI DR
Practice Address - Street 2:
Practice Address - City:EAST PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61611-1840
Practice Address - Country:US
Practice Address - Phone:309-694-6446
Practice Address - Fax:309-698-0650
Is Sole Proprietor?:No
Enumeration Date:2008-07-08
Last Update Date:2009-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146003535235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist