Provider Demographics
NPI:1477070068
Name:WYATT, ARDYN R (CSWA)
Entity Type:Individual
Prefix:MS
First Name:ARDYN
Middle Name:R
Last Name:WYATT
Suffix:
Gender:F
Credentials:CSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2015 NW FLANDERS ST APT 106
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-1165
Mailing Address - Country:US
Mailing Address - Phone:971-352-6971
Mailing Address - Fax:
Practice Address - Street 1:2015 NW FLANDERS ST APT 106
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-1165
Practice Address - Country:US
Practice Address - Phone:971-271-0229
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-24
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORA78741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical