Provider Demographics
NPI:1184701591
Name:WYATT, SARAH REVIS (DPT)
Entity type:Individual
Prefix:MRS
First Name:SARAH
Middle Name:REVIS
Last Name:WYATT
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 HICKORY ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:SC
Mailing Address - Zip Code:29325-2825
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:105 PHYSICIANS PARK DR
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:SC
Practice Address - Zip Code:29325-7551
Practice Address - Country:US
Practice Address - Phone:864-938-0111
Practice Address - Fax:864-938-0811
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3915225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQ33353Medicare UPIN