Provider Demographics
NPI:1467413393
Name:WYATT, KATHERINE D (LCMHC)
Entity Type:Individual
Prefix:MRS
First Name:KATHERINE
Middle Name:D
Last Name:WYATT
Suffix:
Gender:F
Credentials:LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 KELVDON DR
Mailing Address - Street 2:
Mailing Address - City:KERNERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27284-8387
Mailing Address - Country:US
Mailing Address - Phone:252-474-4645
Mailing Address - Fax:
Practice Address - Street 1:110 KELVDON DR
Practice Address - Street 2:
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-8387
Practice Address - Country:US
Practice Address - Phone:252-474-4645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-30
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4900101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC194339OtherMEDCOST
NC831160000OtherMAGELLAN
NC204836896OtherTRICARE
NC2268491OtherCIGNA
NC1400FOtherBC
NC6102822Medicaid