Provider Demographics
NPI:1093598450
Name:WYATT, TAYLOR SHEA (LAPC)
Entity Type:Individual
Prefix:MRS
First Name:TAYLOR
Middle Name:SHEA
Last Name:WYATT
Suffix:
Gender:F
Credentials:LAPC
Other - Prefix:
Other - First Name:TAYLOR
Other - Middle Name:
Other - Last Name:FOWLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4582 VALLEY PKWY SE APT B
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30082-4947
Mailing Address - Country:US
Mailing Address - Phone:918-740-2128
Mailing Address - Fax:
Practice Address - Street 1:500 SUN VALLEY DR STE D2
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-5636
Practice Address - Country:US
Practice Address - Phone:770-910-9162
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-17
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC008066101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health