Provider Demographics
NPI:1912649351
Name:WYATT-LOCUS, KHIANA GRAY (LCSW-A)
Entity Type:Individual
Prefix:
First Name:KHIANA
Middle Name:GRAY
Last Name:WYATT-LOCUS
Suffix:
Gender:F
Credentials:LCSW-A
Other - Prefix:
Other - First Name:KHIANA
Other - Middle Name:GRAY
Other - Last Name:WYATT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:205 W BAYSHORE BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28540-5339
Mailing Address - Country:US
Mailing Address - Phone:910-347-9111
Mailing Address - Fax:910-347-9711
Practice Address - Street 1:205 W BAYSHORE BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28540-5339
Practice Address - Country:US
Practice Address - Phone:910-347-9111
Practice Address - Fax:910-347-9711
Is Sole Proprietor?:No
Enumeration Date:2022-04-07
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0172941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical