Provider Demographics
NPI:1497968911
Name:WYATT, MOLLIE (PHD)
Entity Type:Individual
Prefix:DR
First Name:MOLLIE
Middle Name:
Last Name:WYATT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2637 RIDGEWOOD RD STE 100
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4922
Mailing Address - Country:US
Mailing Address - Phone:601-981-8873
Mailing Address - Fax:
Practice Address - Street 1:2637 RIDGEWOOD RD STE 100
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4922
Practice Address - Country:US
Practice Address - Phone:601-981-8873
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS305103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist