Provider Demographics
NPI:1508281502
Name:WYATT, JULIE (MASTERS)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:
Last Name:WYATT
Suffix:
Gender:F
Credentials:MASTERS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9024 AVENUE POINTE CIR APT 105
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32821-6361
Mailing Address - Country:US
Mailing Address - Phone:774-254-3364
Mailing Address - Fax:
Practice Address - Street 1:9024 AVENUE POINTE CIR APT 105
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32821-6361
Practice Address - Country:US
Practice Address - Phone:774-254-3364
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-27
Last Update Date:2022-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH18321101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIGH57134Medicaid