Provider Demographics
NPI:1518519487
Name:WYETH, CHRISTOPHER M (MS, CCC-SLP)
Entity Type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:M
Last Name:WYETH
Suffix:
Gender:M
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 BROAD ROCK BLVD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23249-0001
Mailing Address - Country:US
Mailing Address - Phone:804-675-5000
Mailing Address - Fax:
Practice Address - Street 1:1201 BROAD ROCK BLVD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23249-0001
Practice Address - Country:US
Practice Address - Phone:804-675-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-11
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202008952235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2202008952OtherCOMMONWEALTH OF VIRGINIA SLP LICENSE
14153091OtherAMERICAN SPEECH-LANGUAGE HEARING ASSOCIATION CERTIFICATE OF CLINICAL COMPETENCE