Provider Demographics
NPI:1295954683
Name:WYLIE, MARY BETH (COTA)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:BETH
Last Name:WYLIE
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 DOWNING HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:WAYNESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:38485-3846
Mailing Address - Country:US
Mailing Address - Phone:931-722-2832
Mailing Address - Fax:
Practice Address - Street 1:409 PARK AVE
Practice Address - Street 2:
Practice Address - City:ADAMSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38310-2461
Practice Address - Country:US
Practice Address - Phone:731-632-3301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1254224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant