Provider Demographics
NPI:1346592359
Name:WYATT, BRENDA (CSAC)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:WYATT
Suffix:
Gender:F
Credentials:CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14489 WHISPERWOOD CT
Mailing Address - Street 2:
Mailing Address - City:DUMFRIES
Mailing Address - State:VA
Mailing Address - Zip Code:22025-1133
Mailing Address - Country:US
Mailing Address - Phone:703-835-6360
Mailing Address - Fax:
Practice Address - Street 1:3300 GALLOWS RD
Practice Address - Street 2:CATS AT FFX HOSPTIAL
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22042-3307
Practice Address - Country:US
Practice Address - Phone:703-289-7573
Practice Address - Fax:703-776-7799
Is Sole Proprietor?:No
Enumeration Date:2012-10-15
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA710102183101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)