Healthcare Provider Details

I. General information

NPI: 1639034747
Provider Name (Legal Business Name): WYATT WELLNESS AND CONSULTING, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2025
Last Update Date: 12/20/2025
Certification Date: 12/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2336 S 5TH ST
SPRINGFIELD IL
62703-3410
US

IV. Provider business mailing address

2336 S 5TH ST
SPRINGFIELD IL
62703-3410
US

V. Phone/Fax

Practice location:
  • Phone: 217-761-7709
  • Fax:
Mailing address:
  • Phone: 217-761-7709
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: REX BLAIR WYATT
Title or Position: LCSW
Credential: MSW, LCSW
Phone: 217-761-7709