Provider Demographics
NPI:1356558183
Name:MEDEARIS, WYLENE
Entity type:Individual
Prefix:MS
First Name:WYLENE
Middle Name:
Last Name:MEDEARIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1607 E PALMDALE BLVD
Mailing Address - Street 2:SUITE G
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93550-4883
Mailing Address - Country:US
Mailing Address - Phone:661-223-5590
Mailing Address - Fax:661-538-9057
Practice Address - Street 1:1607 E PALMDALE BLVD
Practice Address - Street 2:SUITE G
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93550-4883
Practice Address - Country:US
Practice Address - Phone:661-223-5590
Practice Address - Fax:661-538-9057
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA190485AP101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor