Healthcare Provider Details

I. General information

NPI: 1740588557
Provider Name (Legal Business Name): MARK LINSLEY WYATT M.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2011
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

270 EAST LN
BURLINGAME CA
94010-2802
US

IV. Provider business mailing address

17414 NE 31ST ST
VANCOUVER WA
98682-3667
US

V. Phone/Fax

Practice location:
  • Phone: 564-219-0555
  • Fax:
Mailing address:
  • Phone: 564-219-0555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: