Provider Demographics
NPI:1629427091
Name:WYLIE, BRIAN (OTR/L)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:WYLIE
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15451 VENTURA BLVD
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-3014
Mailing Address - Country:US
Mailing Address - Phone:818-788-8870
Mailing Address - Fax:
Practice Address - Street 1:15451 VENTURA BLVD
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-3014
Practice Address - Country:US
Practice Address - Phone:818-788-8870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-07
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT16014225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist