Provider Demographics
NPI:1245221043
Name:WYATT, AMANDA M (MA, ATR-BC, LMHC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:M
Last Name:WYATT
Suffix:
Gender:F
Credentials:MA, ATR-BC, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 WALL ST
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-2512
Mailing Address - Country:US
Mailing Address - Phone:219-531-3500
Mailing Address - Fax:
Practice Address - Street 1:601 WALL ST
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-2512
Practice Address - Country:US
Practice Address - Phone:219-531-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2010-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180-005554101YP2500X
IN39001619A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL180-005554OtherLCPC
IN39001619AOtherLMHC
04-139OtherART THERAPY BD. CERT.