Provider Demographics
NPI:1134172562
Name:WYATT, STEVEN CHARLES (PHD)
Entity type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:CHARLES
Last Name:WYATT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9041 EXECUTIVE PARK DR
Mailing Address - Street 2:SUITE 210
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37923-4621
Mailing Address - Country:US
Mailing Address - Phone:865-603-2192
Mailing Address - Fax:865-381-0544
Practice Address - Street 1:9041 EXECUTIVE PARK DR
Practice Address - Street 2:SUITE 210
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923-4621
Practice Address - Country:US
Practice Address - Phone:865-603-2192
Practice Address - Fax:865-381-0544
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2020-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP2708103TC1900X
TN2708103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6000456Medicaid
NC2829988AMedicare ID - Type Unspecified