Provider Demographics
NPI:1053645796
Name:WYATT, CARMEN MARIA (CADAC)
Entity Type:Individual
Prefix:MRS
First Name:CARMEN
Middle Name:MARIA
Last Name:WYATT
Suffix:
Gender:F
Credentials:CADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 BERQUIST DRIVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:LACKLAND AFB
Mailing Address - State:TX
Mailing Address - Zip Code:78236
Mailing Address - Country:US
Mailing Address - Phone:210-292-4452
Mailing Address - Fax:
Practice Address - Street 1:2200 BERQUIST DRIVE
Practice Address - Street 2:SUITE 1
Practice Address - City:LACKLAND AFB
Practice Address - State:TX
Practice Address - Zip Code:78236
Practice Address - Country:US
Practice Address - Phone:210-292-4452
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-29
Last Update Date:2009-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC2042101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)