Healthcare Provider Details

I. General information

NPI: 1144800517
Provider Name (Legal Business Name): VIRGINIA WYATT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2021
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 DIMOCK ST
ROXBURY MA
02119-1208
US

IV. Provider business mailing address

846 DORCHESTER AVE APT 4
BOSTON MA
02125-1174
US

V. Phone/Fax

Practice location:
  • Phone: 617-442-8800
  • Fax:
Mailing address:
  • Phone: 617-798-0263
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW2143476
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: