Provider Demographics
NPI:1669592424
Name:WYATT, JOHN THOMPSON BRUTON (PHD)
Entity type:Individual
Prefix:
First Name:JOHN THOMPSON
Middle Name:BRUTON
Last Name:WYATT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 PASTEUR DR
Mailing Address - Street 2:SUITE 404
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27403
Mailing Address - Country:US
Mailing Address - Phone:336-299-0609
Mailing Address - Fax:
Practice Address - Street 1:612 PASTEUR DR
Practice Address - Street 2:SUITE 404
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27403
Practice Address - Country:US
Practice Address - Phone:336-299-0609
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1268103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist