Provider Demographics
NPI:1770854879
Name:WYATT, SASHA (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:SASHA
Middle Name:
Last Name:WYATT
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26399 S 515 RD
Mailing Address - Street 2:
Mailing Address - City:PARK HILL
Mailing Address - State:OK
Mailing Address - Zip Code:74451-4082
Mailing Address - Country:US
Mailing Address - Phone:918-931-3171
Mailing Address - Fax:
Practice Address - Street 1:26399 S 515 RD
Practice Address - Street 2:
Practice Address - City:PARK HILL
Practice Address - State:OK
Practice Address - Zip Code:74451-4082
Practice Address - Country:US
Practice Address - Phone:918-931-3171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-20
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK12096938235Z00000X
OK3372235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist