Provider Demographics
NPI:1073991113
Name:WYATT, ANDREA (LPC)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:WYATT
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:
Other - Last Name:MARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2808 SADDLE DR
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76210-0573
Mailing Address - Country:US
Mailing Address - Phone:936-404-9586
Mailing Address - Fax:
Practice Address - Street 1:1512 SCRIPTURE ST
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76201-3916
Practice Address - Country:US
Practice Address - Phone:800-897-7068
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-08
Last Update Date:2015-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX70755101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional