Provider Demographics
NPI:1700890571
Name:WYLIE, SCOTT A (PHD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:A
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:PO BOX 909
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-0909
Mailing Address - Country:US
Mailing Address - Phone:502-588-0325
Mailing Address - Fax:502-588-0326
Practice Address - Street 1:220 ABRAHAM FLEXNER WAY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202
Practice Address - Country:US
Practice Address - Phone:502-899-3626
Practice Address - Fax:502-899-7970
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810003670103G00000X, 103TC0700X
TNPHD3062103TC0700X
KY173223103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0810003670OtherVA STATE LICENSE