MEDICARE: MS. CHEA WYATT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	222Q00000X	Developmental Therapist		IL
2	1041C0700X	Clinical Social Worker	149.031495	IL

General Provider Information

NPI Number	:	1235590100
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CHEA WYATT

Provider Business Mailing Address
First Line	:	112 CHEVY CHASE DR
Second Line	:
City	:	BELLEVILLE
State	:	IL
Zip	:	62223-4120
Country	:	US
Telephone Number	:	618-960-8167
Fax Number	:

Provider Business Practice Location Address
First Line	:	112 CHEVY CHASE DR
Second Line	:
City	:	BELLEVILLE
State	:	IL
Zip	:	62223-4120
Country	:	US
Telephone Number	:	618-960-8167
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/18/2016
Last Update Date	:	03/19/2026

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