Provider Demographics
NPI:1629411319
Name:SCOTT D WYLIE, PSY.D., MSCP, LLC
Entity Type:Organization
Organization Name:SCOTT D WYLIE, PSY.D., MSCP, LLC
Other - Org Name:MEDICAL PSYCHOLOGY ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:DEVERE
Authorized Official - Last Name:WYLIE
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, MSCP
Authorized Official - Phone:888-666-0974
Mailing Address - Street 1:113 CORONADO CT
Mailing Address - Street 2:SUITE 202
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-4911
Mailing Address - Country:US
Mailing Address - Phone:888-666-0974
Mailing Address - Fax:970-223-4433
Practice Address - Street 1:113 CORONADO CT
Practice Address - Street 2:SUITE 202
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-4911
Practice Address - Country:US
Practice Address - Phone:888-666-0974
Practice Address - Fax:970-223-4433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-11
Last Update Date:2018-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2962103G00000X, 103TC0700X, 103TP0016X, 261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Single Specialty
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1629411319Medicaid
WY135497300Medicaid
CO1669497111OtherINDIVIDUAL NPI
CO1669497111OtherINDIVIDUAL NPI
CO1629411319Medicaid
WYW25383Medicare PIN