Provider Demographics
NPI:1891237434
Name:WYLIE & ASSOCIATES BEHAVIORAL HEALTH LLC
Entity Type:Organization
Organization Name:WYLIE & ASSOCIATES BEHAVIORAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:APN MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:WYLIE
Authorized Official - Suffix:
Authorized Official - Credentials:RN MSN CNS APN
Authorized Official - Phone:618-593-0134
Mailing Address - Street 1:118 SEMINARY STREET
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62234
Mailing Address - Country:US
Mailing Address - Phone:618-855-8815
Mailing Address - Fax:
Practice Address - Street 1:118 S SEMINARY ST
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62234-2634
Practice Address - Country:US
Practice Address - Phone:618-855-8815
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-14
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209005228103TP0016X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1083735443OtherINDIVIDUAL NPI MELANIE WYLIE