Provider Demographics
NPI:1700914801
Name:WYLIE, DERRICO (PHD, LCPC, NCC)
Entity Type:Individual
Prefix:DR
First Name:DERRICO
Middle Name:
Last Name:WYLIE
Suffix:
Gender:M
Credentials:PHD, LCPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5713 LINDA LN
Mailing Address - Street 2:
Mailing Address - City:CAMP SPRINGS
Mailing Address - State:MD
Mailing Address - Zip Code:20748-2331
Mailing Address - Country:US
Mailing Address - Phone:615-300-7092
Mailing Address - Fax:
Practice Address - Street 1:5713 LINDA LN
Practice Address - Street 2:
Practice Address - City:CAMP SPRINGS
Practice Address - State:MD
Practice Address - Zip Code:20748-2331
Practice Address - Country:US
Practice Address - Phone:615-300-7092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2019-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health