Provider Demographics
NPI:1669557690
Name:WYANT, ELIZABETH BLACK (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:BLACK
Last Name:WYANT
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
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Mailing Address - Street 1:23835 HIGHWAY 24
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:MO
Mailing Address - Zip Code:65275-2276
Mailing Address - Country:US
Mailing Address - Phone:660-327-1402
Mailing Address - Fax:660-327-1403
Practice Address - Street 1:23835 HIGHWAY 24
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:MO
Practice Address - Zip Code:65275-2276
Practice Address - Country:US
Practice Address - Phone:660-327-1402
Practice Address - Fax:660-327-1403
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO113584235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist