Provider Demographics
NPI:1134768443
Name:WYATT, ANDRIA (BCBA, LBA)
Entity type:Individual
Prefix:
First Name:ANDRIA
Middle Name:
Last Name:WYATT
Suffix:
Gender:F
Credentials:BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11661 PRESTON RD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-2745
Mailing Address - Country:US
Mailing Address - Phone:605-220-6734
Mailing Address - Fax:
Practice Address - Street 1:11661 PRESTON RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-2745
Practice Address - Country:US
Practice Address - Phone:214-251-8757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-03
Last Update Date:2020-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA103K00000X
TX3301103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst