Provider Demographics
NPI:1902190986
Name:WYATT, REBECCA MAXINE (CADC, CCJP, CSC)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:MAXINE
Last Name:WYATT
Suffix:
Gender:F
Credentials:CADC, CCJP, CSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 S MARKET ST
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23803-4216
Mailing Address - Country:US
Mailing Address - Phone:804-691-6144
Mailing Address - Fax:
Practice Address - Street 1:4 S MARKET ST
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23803-4216
Practice Address - Country:US
Practice Address - Phone:804-691-6144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-07
Last Update Date:2011-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA704151101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)