Provider Demographics
NPI:1972273878
Name:WYATT, LISA MARIE (MSW)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:WYATT
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 TECH CENTER DR
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37912-2747
Mailing Address - Country:US
Mailing Address - Phone:956-878-9881
Mailing Address - Fax:
Practice Address - Street 1:600 ARTHUR ST
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37921-6405
Practice Address - Country:US
Practice Address - Phone:865-523-8695
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-14
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP016069101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor