| Doctor Name: | MARK WYLY |
| NPI Number: | 1093065617 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | |
| License Number: | |
| Business Practice Address: | 768 Pleasant Valley Rd Ste. 304 Diamond Springs, CA - 956199260 |
| Business Phone Number: | 5306219800 |
| Business Fax Number: | |
| Mailing Address: | 1202 School St, FOLSOM |
| State: | CA |
| Postal Code: | 956303309 |
| Phone Number: | 5306219800 |
| Fax Number: | |
| NPI Enumeration Date: | 09/11/2012 |
| NPI Last Update Date: | 09/11/2012 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YM0800X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Mental Health |
| Taxonomy Definition: | |