Provider Demographics
NPI:1437139607
Name:WYATT, CAROLYN J (PHD)
Entity Type:Individual
Prefix:DR
First Name:CAROLYN
Middle Name:J
Last Name:WYATT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 HAYWARD RD
Mailing Address - Street 2:
Mailing Address - City:PULLMAN
Mailing Address - State:WA
Mailing Address - Zip Code:99163-8949
Mailing Address - Country:US
Mailing Address - Phone:509-332-6417
Mailing Address - Fax:509-332-6417
Practice Address - Street 1:814 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-3049
Practice Address - Country:US
Practice Address - Phone:208-883-0619
Practice Address - Fax:208-882-4774
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-22
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY-188103TC1900X
WA#1017103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID145779137335OtherPREMERA BLUE CROSS
ID000010015935OtherREGENCE BLUE SHIELD
ID8D236OtherBLUE CROSS OF IDAHO
ID145779137335OtherPREMERA BLUE CROSS