Provider Demographics
NPI:1497809347
Name:WYATT, MARIA LARA
Entity Type:Individual
Prefix:MRS
First Name:MARIA
Middle Name:LARA
Last Name:WYATT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARIA
Other - Middle Name:ISABEL
Other - Last Name:LARA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:667 LEE RD
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL
Mailing Address - State:CA
Mailing Address - Zip Code:92251-9503
Mailing Address - Country:US
Mailing Address - Phone:760-355-0044
Mailing Address - Fax:
Practice Address - Street 1:1295 W STATE ST STE 102
Practice Address - Street 2:
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-2881
Practice Address - Country:US
Practice Address - Phone:760-353-0763
Practice Address - Fax:760-352-4061
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)