Provider Demographics
NPI:1336278936
Name:WYATT, EMILY BASS (ST)
Entity Type:Individual
Prefix:MRS
First Name:EMILY
Middle Name:BASS
Last Name:WYATT
Suffix:
Gender:F
Credentials:ST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2606 BELOIT ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-2515
Mailing Address - Country:US
Mailing Address - Phone:318-680-1618
Mailing Address - Fax:318-329-3666
Practice Address - Street 1:901 N 4TH ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-5909
Practice Address - Country:US
Practice Address - Phone:318-387-7817
Practice Address - Fax:318-322-0914
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6558146235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1408026Medicaid