Provider Demographics
NPI:1235590100
Name:WYATT, CHEA
Entity Type:Individual
Prefix:MS
First Name:CHEA
Middle Name:
Last Name:WYATT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 CHEVY CHASE DR
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223-4120
Mailing Address - Country:US
Mailing Address - Phone:618-960-8167
Mailing Address - Fax:
Practice Address - Street 1:112 CHEVY CHASE DR
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62223-4120
Practice Address - Country:US
Practice Address - Phone:618-960-8167
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-18
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist