Provider Demographics
NPI:1932315066
Name:WYLLIE, PATRICIA DIANE (QMHP)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:DIANE
Last Name:WYLLIE
Suffix:
Gender:F
Credentials:QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2060 EMERALD ST
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97403-1525
Mailing Address - Country:US
Mailing Address - Phone:541-228-6778
Mailing Address - Fax:
Practice Address - Street 1:175 W B ST STE I
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-4575
Practice Address - Country:US
Practice Address - Phone:541-988-1025
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health