Provider Demographics
NPI:1740508894
Name:WYATT, ROLLYN K (LISW-S)
Entity type:Individual
Prefix:
First Name:ROLLYN
Middle Name:K
Last Name:WYATT
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22655 CHAGRIN BLVD
Mailing Address - Street 2:109
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-5336
Mailing Address - Country:US
Mailing Address - Phone:216-751-2368
Mailing Address - Fax:
Practice Address - Street 1:22655 CHAGRIN BLVD
Practice Address - Street 2:109
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-5336
Practice Address - Country:US
Practice Address - Phone:216-751-2368
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-13
Last Update Date:2010-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0004394-S1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical