Provider Demographics
NPI:1568972552
Name:WYATT, MARIAH MERCEDES
Entity Type:Individual
Prefix:
First Name:MARIAH
Middle Name:MERCEDES
Last Name:WYATT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 NW TRINITY PL APT 1
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-1929
Mailing Address - Country:US
Mailing Address - Phone:503-508-4848
Mailing Address - Fax:
Practice Address - Street 1:9300 NE OAK VIEW DR
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98662-6157
Practice Address - Country:US
Practice Address - Phone:360-567-2211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-04
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor