Provider Demographics
NPI:1336209774
Name:WYLIE, THOMAS FREDERICK (PHD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:FREDERICK
Last Name:WYLIE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11573 LOS OSOS VALLEY RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93405-6473
Mailing Address - Country:US
Mailing Address - Phone:805-545-8951
Mailing Address - Fax:805-545-8951
Practice Address - Street 1:11573 LOS OSOS VALLEY RD
Practice Address - Street 2:SUITE C
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-6473
Practice Address - Country:US
Practice Address - Phone:805-545-8951
Practice Address - Fax:805-545-8951
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY12486103G00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP12486Medicare ID - Type Unspecified
CAR16058Medicare UPIN