Provider Demographics
NPI:1023844743
Name:WYGANT, SHAWN ANDREW (MA)
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:ANDREW
Last Name:WYGANT
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 OTTAWA CT
Mailing Address - Street 2:
Mailing Address - City:OSCODA
Mailing Address - State:MI
Mailing Address - Zip Code:48750-1462
Mailing Address - Country:US
Mailing Address - Phone:989-335-5134
Mailing Address - Fax:989-739-1417
Practice Address - Street 1:208 OTTAWA CT
Practice Address - Street 2:
Practice Address - City:OSCODA
Practice Address - State:MI
Practice Address - Zip Code:48750-1462
Practice Address - Country:US
Practice Address - Phone:989-335-5134
Practice Address - Fax:989-739-1417
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-10
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6352000017103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic