Provider Demographics
NPI:1851530786
Name:WYATT, TRACEY (LPC)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:WYATT
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30601-2244
Mailing Address - Country:US
Mailing Address - Phone:706-542-9700
Mailing Address - Fax:706-227-7249
Practice Address - Street 1:165 E DOUGHERTY ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30601-2608
Practice Address - Country:US
Practice Address - Phone:706-542-9700
Practice Address - Fax:706-227-7249
Is Sole Proprietor?:No
Enumeration Date:2009-02-17
Last Update Date:2010-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC001877101Y00000X
GALPC006178101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor