Provider Demographics
NPI:1336718287
Name:JASON WYATT, LPCC, LLC
Entity Type:Organization
Organization Name:JASON WYATT, LPCC, LLC
Other - Org Name:EXCELSIOR MENTAL HEALTH SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:WYATT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-642-5544
Mailing Address - Street 1:PO BOX 375
Mailing Address - Street 2:
Mailing Address - City:FAIRACRES
Mailing Address - State:NM
Mailing Address - Zip Code:88033-0375
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1705 N VALLEY DR STE 12
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88007-5121
Practice Address - Country:US
Practice Address - Phone:575-642-5544
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-23
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM61121282Medicaid