Provider Demographics
NPI:1730675968
Name:WYATT, KAITLYN MICHELLE (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:MICHELLE
Last Name:WYATT
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3511 PROVOST ST
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27603-3678
Mailing Address - Country:US
Mailing Address - Phone:818-970-3806
Mailing Address - Fax:
Practice Address - Street 1:4909 WATERS EDGE DR
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27606-2462
Practice Address - Country:US
Practice Address - Phone:919-285-1647
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-11
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC13127235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist