Provider Demographics
NPI:1578655460
Name:WYATT, MASSI HUGH (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MASSI
Middle Name:HUGH
Last Name:WYATT
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 ANDREWS AVE
Mailing Address - Street 2:BEHAVIORAL HEALTH
Mailing Address - City:FORT RUCKER
Mailing Address - State:AL
Mailing Address - Zip Code:36362
Mailing Address - Country:US
Mailing Address - Phone:334-255-7028
Mailing Address - Fax:334-255-7528
Practice Address - Street 1:301 ANDREWS AVE
Practice Address - Street 2:BEHAVIORAL HEALTH
Practice Address - City:FORT RUCKER
Practice Address - State:AL
Practice Address - Zip Code:36362-5333
Practice Address - Country:US
Practice Address - Phone:334-255-7028
Practice Address - Fax:334-255-7528
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2012-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1280103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1280OtherALABAMA ST. BOARD
MT2210068Medicaid
Q09697Medicare UPIN