1629411319 NPI number — SCOTT D WYLIE, PSY.D., MSCP, LLC

Table of content: (NPI 1629411319)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629411319 NPI number — SCOTT D WYLIE, PSY.D., MSCP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SCOTT D WYLIE, PSY.D., MSCP, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1629411319
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/07/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
113 CORONADO CT
Provider Second Line Business Mailing Address:
SUITE 202
Provider Business Mailing Address City Name:
FORT COLLINS
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80525-4911
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-666-0974
Provider Business Mailing Address Fax Number:
970-223-4433

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
113 CORONADO CT
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
FORT COLLINS
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80525-4911
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-666-0974
Provider Business Practice Location Address Fax Number:
970-223-4433
Provider Enumeration Date:
04/11/2013

Additional Information

Authorized Official

Authorized Official Last Name:
WYLIE
Authorized Official First Name:
SCOTT
Authorized Official Middle Name:
DEVERE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
888-666-0974

Provider Taxonomy Codes

  • Taxonomy code: 103G00000X , with the licence number:  2962 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC0700X , with the licence number: 2962 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TP0016X , with the licence number: 2962 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM1300X , with the licence number: 2962 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1629411319 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 135497300 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1669497111 . This is a "INDIVIDUAL NPI" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".




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