Provider Demographics
NPI:1588216899
Name:TRAMMELL, WYATT EVERETT (CADC-CAS, SUDDC)
Entity Type:Individual
Prefix:
First Name:WYATT
Middle Name:EVERETT
Last Name:TRAMMELL
Suffix:
Gender:M
Credentials:CADC-CAS, SUDDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1341
Mailing Address - Street 2:
Mailing Address - City:ANGELS CAMP
Mailing Address - State:CA
Mailing Address - Zip Code:95222-1341
Mailing Address - Country:US
Mailing Address - Phone:209-608-0700
Mailing Address - Fax:209-754-6559
Practice Address - Street 1:891 MOUNTAIN RANCH RD
Practice Address - Street 2:
Practice Address - City:SAN ANDREAS
Practice Address - State:CA
Practice Address - Zip Code:95249-9713
Practice Address - Country:US
Practice Address - Phone:209-608-0700
Practice Address - Fax:209-754-6559
Is Sole Proprietor?:No
Enumeration Date:2019-07-16
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9199101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)