Provider Demographics
NPI:1942251939
Name:WYLIN, GARY THOMAS (LCSW)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:THOMAS
Last Name:WYLIN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 N HEPBURN AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-5015
Mailing Address - Country:US
Mailing Address - Phone:561-743-1408
Mailing Address - Fax:561-743-1403
Practice Address - Street 1:609 N HEPBURN AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-5015
Practice Address - Country:US
Practice Address - Phone:561-743-1408
Practice Address - Fax:561-743-1403
Is Sole Proprietor?:No
Enumeration Date:2006-05-13
Last Update Date:2009-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW21311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ2786Medicare ID - Type Unspecified