Provider Demographics
NPI:1467330167
Name:WYATT, KIMBERLY
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:WYATT
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4023 AMBASSADOR CAFFERY PKWY STE 507
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-5268
Mailing Address - Country:US
Mailing Address - Phone:337-284-0820
Mailing Address - Fax:
Practice Address - Street 1:4023 AMBASSADOR CAFFERY PKWY STE 507
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-5268
Practice Address - Country:US
Practice Address - Phone:337-284-0820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-22
Last Update Date:2025-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional