Provider Demographics
NPI:1689044588
Name:WYATT, EARNEST (LPC)
Entity Type:Individual
Prefix:
First Name:EARNEST
Middle Name:
Last Name:WYATT
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2414 FERRAND ST
Mailing Address - Street 2:2
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-3249
Mailing Address - Country:US
Mailing Address - Phone:318-342-9979
Mailing Address - Fax:318-342-9980
Practice Address - Street 1:2414 FERRAND ST
Practice Address - Street 2:2
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-3249
Practice Address - Country:US
Practice Address - Phone:318-342-9979
Practice Address - Fax:318-342-9980
Is Sole Proprietor?:No
Enumeration Date:2015-10-05
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5202101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional