Healthcare Provider Details

I. General information

NPI: 1962493221
Provider Name (Legal Business Name): DEBRA LYNN WYATT M.S.W., L.C.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2005
Last Update Date: 07/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HC 1 BOX 776 715 LEUCKEL DRIVE
VAN BUREN MO
63965-9733
US

IV. Provider business mailing address

HC 1 BOX 776 715 LEUCKEL DRIVE
VAN BUREN MO
63965-9733
US

V. Phone/Fax

Practice location:
  • Phone: 573-300-7506
  • Fax:
Mailing address:
  • Phone: 573-300-7506
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2001005008
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: