Healthcare Provider Details

I. General information

NPI: 1306966619
Provider Name (Legal Business Name): RENEE E WYATT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 08/22/2022
Certification Date: 08/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 PINE AVE
LONG BEACH CA
90802-3041
US

IV. Provider business mailing address

200 PINE AVE STE 400
LONG BEACH CA
90802-3039
US

V. Phone/Fax

Practice location:
  • Phone: 424-599-1476
  • Fax:
Mailing address:
  • Phone: 424-599-1476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberASW73963
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: