Provider Demographics
NPI:1851490817
Name:WYLIE, JUDY M (LPC)
Entity Type:Individual
Prefix:MRS
First Name:JUDY
Middle Name:M
Last Name:WYLIE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1426 EAGLE RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WILDWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63038-2418
Mailing Address - Country:US
Mailing Address - Phone:636-394-6119
Mailing Address - Fax:636-458-0911
Practice Address - Street 1:16917 MANCHESTER RD
Practice Address - Street 2:
Practice Address - City:GROVER
Practice Address - State:MO
Practice Address - Zip Code:63040-1209
Practice Address - Country:US
Practice Address - Phone:314-517-5410
Practice Address - Fax:636-458-0911
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO002288101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional