Healthcare Provider Details

I. General information

NPI: 1336278936
Provider Name (Legal Business Name): EMILY BASS WYATT ST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 01/11/2022
Certification Date: 01/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 N 4TH ST
MONROE LA
71201-5909
US

IV. Provider business mailing address

2606 BELOIT ST
MONROE LA
71201-2515
US

V. Phone/Fax

Practice location:
  • Phone: 318-387-7817
  • Fax: 318-322-0914
Mailing address:
  • Phone: 318-680-1618
  • Fax: 318-329-3666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number6558146
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: