Provider Demographics
NPI:1457417644
Name:WYATT, LISA A (MS)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:A
Last Name:WYATT
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3795 E SHIELDS AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93726-7029
Mailing Address - Country:US
Mailing Address - Phone:559-229-3561
Mailing Address - Fax:
Practice Address - Street 1:3795 E SHIELDS AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93726-7029
Practice Address - Country:US
Practice Address - Phone:559-229-3561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist