Provider Demographics
NPI:1407176605
Name:ELIZABETH B WYATT PHD INC
Entity Type:Organization
Organization Name:ELIZABETH B WYATT PHD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:BLAIR
Authorized Official - Last Name:WYATT
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:440-269-1500
Mailing Address - Street 1:8039 BROADMOOR RD
Mailing Address - Street 2:SUITE 15
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-7577
Mailing Address - Country:US
Mailing Address - Phone:440-269-1500
Mailing Address - Fax:440-269-8545
Practice Address - Street 1:8039 BROADMOOR RD
Practice Address - Street 2:SUITE 15
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-7577
Practice Address - Country:US
Practice Address - Phone:440-269-1500
Practice Address - Fax:440-269-8545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-10
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4508103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty