Provider Demographics
NPI:1043085277
Name:WYATT, LAUREL (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LAUREL
Middle Name:
Last Name:WYATT
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 HUNGERFORD DR
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-1718
Mailing Address - Country:US
Mailing Address - Phone:240-740-5500
Mailing Address - Fax:
Practice Address - Street 1:400 VICTORY FARM DRIVE
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20877
Practice Address - Country:US
Practice Address - Phone:240-740-6770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-17
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD10886235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist