Provider Demographics
NPI:1285467720
Name:WYLIE, MICAH ALDEN (SLP)
Entity type:Individual
Prefix:MR
First Name:MICAH
Middle Name:ALDEN
Last Name:WYLIE
Suffix:
Gender:M
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1185 FIR ACRES DR
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-1884
Mailing Address - Country:US
Mailing Address - Phone:310-666-8623
Mailing Address - Fax:
Practice Address - Street 1:3720 N CLAREY ST
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97402-8744
Practice Address - Country:US
Practice Address - Phone:458-201-4936
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-21
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR17838235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist