Provider Demographics
NPI:1679974265
Name:WYVRATT, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:WYVRATT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11283 RIDDLE DR
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34609-3441
Mailing Address - Country:US
Mailing Address - Phone:724-880-0818
Mailing Address - Fax:
Practice Address - Street 1:201 WOOD ST
Practice Address - Street 2:
Practice Address - City:SISTERSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26175-1523
Practice Address - Country:US
Practice Address - Phone:304-652-1032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-15
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ6876235Z00000X
WVSLP-2379235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL013444700Medicaid