Provider Demographics
NPI:1417413089
Name:WYATT, TONI (LMSW)
Entity Type:Individual
Prefix:
First Name:TONI
Middle Name:
Last Name:WYATT
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6200 PERSHING AVE APT 346
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76116-2618
Mailing Address - Country:US
Mailing Address - Phone:214-686-0023
Mailing Address - Fax:
Practice Address - Street 1:6200 PERSHING AVE APT 346
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76116-2618
Practice Address - Country:US
Practice Address - Phone:214-686-0023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-19
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX64742251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management