Provider Demographics
NPI:1073576690
Name:WYATT, PAUL DOUGLAS (EDD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:DOUGLAS
Last Name:WYATT
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2271 UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-7083
Mailing Address - Country:US
Mailing Address - Phone:916-488-2919
Mailing Address - Fax:916-488-2919
Practice Address - Street 1:828 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-6723
Practice Address - Country:US
Practice Address - Phone:916-565-1919
Practice Address - Fax:916-488-2919
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 3094106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist