Provider Demographics
NPI:1437380706
Name:WYATT, GWENDOLYNN (SLP)
Entity Type:Individual
Prefix:MS
First Name:GWENDOLYNN
Middle Name:
Last Name:WYATT
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 E VAN DORN AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLY SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:38635-2515
Mailing Address - Country:US
Mailing Address - Phone:662-544-6156
Mailing Address - Fax:
Practice Address - Street 1:540 E VAN DORN AVE
Practice Address - Street 2:
Practice Address - City:HOLLY SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:38635-2515
Practice Address - Country:US
Practice Address - Phone:662-544-6156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-04
Last Update Date:2009-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS3384235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist