Provider Demographics
NPI:1669595740
Name:WYATT, ALLAN (PSYD)
Entity type:Individual
Prefix:DR
First Name:ALLAN
Middle Name:
Last Name:WYATT
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:187 CONCORD RD
Mailing Address - Street 2:
Mailing Address - City:WAYLAND
Mailing Address - State:MA
Mailing Address - Zip Code:01778-1205
Mailing Address - Country:US
Mailing Address - Phone:508-358-3546
Mailing Address - Fax:508-358-2149
Practice Address - Street 1:586 MAIN ST
Practice Address - Street 2:
Practice Address - City:SHREWSBURY
Practice Address - State:MA
Practice Address - Zip Code:01545-2920
Practice Address - Country:US
Practice Address - Phone:508-358-2144
Practice Address - Fax:508-358-2149
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4515103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW04353OtherBLUE CRO