Provider Demographics
NPI:1639467830
Name:WYLIE, SAMUEL (LPC)
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:
Last Name:WYLIE
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3136 EXECUTIVE DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76904-6802
Mailing Address - Country:US
Mailing Address - Phone:325-234-8955
Mailing Address - Fax:
Practice Address - Street 1:3136 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76904-6802
Practice Address - Country:US
Practice Address - Phone:325-944-3692
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-21
Last Update Date:2015-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11531101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTPI - 025674502Medicaid