Provider Demographics
NPI:1255606695
Name:WYATT, ROSE MARIE (LCSW)
Entity type:Individual
Prefix:MRS
First Name:ROSE
Middle Name:MARIE
Last Name:WYATT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:ROSE
Other - Middle Name:MARIE
Other - Last Name:KENNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:5201 S CORNELL AVE APT 8C
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-4202
Mailing Address - Country:US
Mailing Address - Phone:773-852-7420
Mailing Address - Fax:
Practice Address - Street 1:5201 S CORNELL AVE APT 8C
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-4202
Practice Address - Country:US
Practice Address - Phone:773-852-7420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-19
Last Update Date:2012-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490002391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical