Provider Demographics
NPI:1134539299
Name:WYATT, THERESE K (LAPC)
Entity type:Individual
Prefix:MRS
First Name:THERESE
Middle Name:K
Last Name:WYATT
Suffix:
Gender:F
Credentials:LAPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 WILEY BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-4628
Mailing Address - Country:US
Mailing Address - Phone:678-898-2335
Mailing Address - Fax:
Practice Address - Street 1:2993 SANDY PLAINS RD
Practice Address - Street 2:SUITE 115
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30066-4695
Practice Address - Country:US
Practice Address - Phone:770-910-2753
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-29
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC004095101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health