Provider Demographics
NPI:1134345424
Name:WYLIE, JUSTIN JAY
Entity type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:JAY
Last Name:WYLIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3274 ROSECRANS ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-4836
Mailing Address - Country:US
Mailing Address - Phone:619-226-2663
Mailing Address - Fax:619-226-2837
Practice Address - Street 1:3274 ROSECRANS ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-4836
Practice Address - Country:US
Practice Address - Phone:619-226-2663
Practice Address - Fax:619-226-2837
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)