Provider Demographics
NPI:1942489901
Name:WYATT, JUDITH LOIS (MFT)
Entity Type:Individual
Prefix:MS
First Name:JUDITH
Middle Name:LOIS
Last Name:WYATT
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:MRS
Other - First Name:JUDITH
Other - Middle Name:LOIS
Other - Last Name:HENDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:492 FAIR OAKS STREET
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94110-3619
Mailing Address - Country:US
Mailing Address - Phone:415-285-4957
Mailing Address - Fax:
Practice Address - Street 1:3644 24TH STREET
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110
Practice Address - Country:US
Practice Address - Phone:415-282-8930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-26
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT19251106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist