Provider Demographics
NPI:1295278810
Name:WYLIE, SAMANTHA (LMFTA)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:WYLIE
Suffix:
Gender:F
Credentials:LMFTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3220 TRIMBLESTONE LN
Mailing Address - Street 2:APT 302
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-5931
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3220 TRIMBLESTONE LN
Practice Address - Street 2:APT 302
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27616-5931
Practice Address - Country:US
Practice Address - Phone:248-990-6153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-30
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12010A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist