Healthcare Provider Details

I. General information

NPI: 1508535162
Provider Name (Legal Business Name): WYATT THOMAS BROOKS MHP, RBT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2021
Last Update Date: 09/08/2021
Certification Date: 09/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10273 YELLOW CIRCLE DR
MINNETONKA MN
55343-9144
US

IV. Provider business mailing address

1918 NEWTON AVE N
MINNEAPOLIS MN
55411-2461
US

V. Phone/Fax

Practice location:
  • Phone: 952-401-9359
  • Fax:
Mailing address:
  • Phone: 608-436-1463
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-20-135436
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: