Provider Demographics
NPI:1508535162
Name:BROOKS, WYATT THOMAS (MHP, RBT)
Entity Type:Individual
Prefix:MR
First Name:WYATT
Middle Name:THOMAS
Last Name:BROOKS
Suffix:
Gender:M
Credentials:MHP, RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1918 NEWTON AVE N
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55411-2461
Mailing Address - Country:US
Mailing Address - Phone:608-436-1463
Mailing Address - Fax:
Practice Address - Street 1:10273 YELLOW CIRCLE DR
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55343-9144
Practice Address - Country:US
Practice Address - Phone:952-401-9359
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-08
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNRBT-20-135436106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNRBT-20-135436OtherBEHAVIOR ANALYST CERTIFICATION BOARD