Healthcare Provider Details

I. General information

NPI: 1376353052
Provider Name (Legal Business Name): WYATT LEWALLEN LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2025
Last Update Date: 01/13/2025
Certification Date: 01/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43585 MONTEREY AVE STE 1
PALM DESERT CA
92260-9398
US

IV. Provider business mailing address

43585 MONTEREY AVE STE 1
PALM DESERT CA
92260-9398
US

V. Phone/Fax

Practice location:
  • Phone: 760-563-6623
  • Fax:
Mailing address:
  • Phone: 760-563-6623
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number151457
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: