Provider Demographics
NPI:1669497111
Name:WYLIE, SCOTT DEVERE (PSYD, MSCP)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:DEVERE
Last Name:WYLIE
Suffix:
Gender:M
Credentials:PSYD, MSCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 CORONADO CT
Mailing Address - Street 2:STE 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
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2018-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY478103G00000X, 103TC0700X
CAPSY18408103TC0700X
CO2962103TC0700X, 103TF0200X, 103TH0004X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1629411319OtherTYPE 2 NPI
WY128459200Medicaid
CO1669497111Medicaid
WY462318597OtherTAX ID
CO306822Medicare PIN
WYW25383Medicare PIN