Provider Demographics
NPI:1982374013
Name:WYATT SPEECH THERAPY SERVICES, PLLC
Entity Type:Organization
Organization Name:WYATT SPEECH THERAPY SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH-LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:SASHA
Authorized Official - Middle Name:
Authorized Official - Last Name:WYATT
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC-SLP
Authorized Official - Phone:918-931-3171
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
Mailing Address - Country:US
Mailing Address - Phone:918-207-9073
Mailing Address - Fax:
Practice Address - Street 1:407 S MUSKOGEE AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-4427
Practice Address - Country:US
Practice Address - Phone:918-931-3171
Practice Address - Fax:877-540-0882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-20
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1770854879Medicaid