Provider Demographics
NPI:1043045883
Name:WYLIE, CHRISTIAN FAITH
Entity type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:FAITH
Last Name:WYLIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHRISTIAN
Other - Middle Name:FAITH
Other - Last Name:SUTTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3126 STATE ST STE 100
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8665
Mailing Address - Country:US
Mailing Address - Phone:458-225-9358
Mailing Address - Fax:
Practice Address - Street 1:4439 HAMRICK RD
Practice Address - Street 2:
Practice Address - City:CENTRAL POINT
Practice Address - State:OR
Practice Address - Zip Code:97502-2816
Practice Address - Country:US
Practice Address - Phone:541-727-7669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-03
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR23-QMHA-R-3574101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500825607Medicaid