Individual
KELLY DIANE WYLIE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
756 PURPLE SAGE RD, BANDERA, TX 78003-3981
(830) 225-1622
Mailing address
21300 STATE HIGHWAY 16 N UNIT 214, MEDINA, TX 78055-3819
(830) 398-0414
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
64298
TX
Other
Enumeration date
09/13/2023
Last updated
09/13/2023
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