Healthcare Provider Details

I. General information

NPI: 1659421212
Provider Name (Legal Business Name): JAMES KELLEY WYATT PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2007
Last Update Date: 04/06/2022
Certification Date: 04/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1653 W CONGRESS PKWY SLEEP DISORDERS CENTER, RUSH UNIVERSITY MEDICAL CENTER
CHICAGO IL
60612-3833
US

IV. Provider business mailing address

1653 W CONGRESS PKWY SLEEP DISORDERS CENTER, RUSH UNIVERSITY MEDICAL CENTER
CHICAGO IL
60612-3833
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-5440
  • Fax: 312-942-8961
Mailing address:
  • Phone: 312-942-5440
  • Fax: 312-942-8961

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number071005918
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number071005918
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number071005918
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071005918
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: