Provider Demographics
NPI:1013110055
Name:WYATT-KIRKEBY, TONI (LCSW)
Entity Type:Individual
Prefix:MS
First Name:TONI
Middle Name:
Last Name:WYATT-KIRKEBY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1620 THOMPSON RD
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-2150
Mailing Address - Country:US
Mailing Address - Phone:541-269-2986
Mailing Address - Fax:541-266-8640
Practice Address - Street 1:1620 THOMPSON RD
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2150
Practice Address - Country:US
Practice Address - Phone:541-269-2986
Practice Address - Fax:541-266-8640
Is Sole Proprietor?:No
Enumeration Date:2007-06-07
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL 14371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical