Provider Demographics
NPI:1457409039
Name:WYATT, CHENE (OTRL)
Entity Type:Individual
Prefix:MRS
First Name:CHENE
Middle Name:
Last Name:WYATT
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:CHENE
Other - Middle Name:
Other - Last Name:PANAGOPOULOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:5050 RESEARCH CT
Mailing Address - Street 2:SUITE 800
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-6606
Mailing Address - Country:US
Mailing Address - Phone:770-205-5551
Mailing Address - Fax:
Practice Address - Street 1:5050 RESEARCH CT
Practice Address - Street 2:SUITE 800
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-6606
Practice Address - Country:US
Practice Address - Phone:770-205-5551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT003813225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA330870519AMedicaid
GA330870519BMedicaid