Provider Demographics
NPI:1972242857
Name:WYLIE, KRISTIN (MS, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:KRISTIN
Middle Name:
Last Name:WYLIE
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3737 FENTON AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76133-2915
Mailing Address - Country:US
Mailing Address - Phone:817-905-6874
Mailing Address - Fax:
Practice Address - Street 1:3737 FENTON AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76133-2915
Practice Address - Country:US
Practice Address - Phone:817-905-6874
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-31
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1467509224Medicaid