Provider Demographics
NPI:1477085769
Name:WYANT, MICHAEL (LICDC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:WYANT
Suffix:
Gender:M
Credentials:LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1302 WINSLOW AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44113-2336
Mailing Address - Country:US
Mailing Address - Phone:440-396-5069
Mailing Address - Fax:167-711-5632
Practice Address - Street 1:1302 WINSLOW AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44113-2336
Practice Address - Country:US
Practice Address - Phone:440-396-5069
Practice Address - Fax:216-771-1563
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-28
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLICDC.161921101YA0400X
OH104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCDCA.162100OtherLICENSE