Provider Demographics
NPI:1417166224
Name:WYATT, TINA (LPC,)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:WYATT
Suffix:
Gender:F
Credentials:LPC,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3358
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28145-3358
Mailing Address - Country:US
Mailing Address - Phone:704-798-9460
Mailing Address - Fax:
Practice Address - Street 1:1121 OLD CONCORD RD STE 23
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28146
Practice Address - Country:US
Practice Address - Phone:704-798-9460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2019-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6645101YP2500X, 101YM0800X
NC1086 ASSOCIATE106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist