Provider Demographics
NPI:1629791256
Name:WYATT, AUSTIN BLAIN (LBSW)
Entity Type:Individual
Prefix:
First Name:AUSTIN
Middle Name:BLAIN
Last Name:WYATT
Suffix:
Gender:M
Credentials:LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7915 COUNTY ROAD 20
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:AL
Mailing Address - Zip Code:35983-5126
Mailing Address - Country:US
Mailing Address - Phone:256-706-2091
Mailing Address - Fax:
Practice Address - Street 1:118 E CHOCCOLOCCO ST
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:AL
Practice Address - Zip Code:36203-1222
Practice Address - Country:US
Practice Address - Phone:256-831-4601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-20
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL6271B104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker