Healthcare Provider Details

I. General information

NPI: 1104914209
Provider Name (Legal Business Name): KATHRYN P. WYATT PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 08/13/2021
Certification Date: 08/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N ELM ST
GREENSBORO NC
27401-1004
US

IV. Provider business mailing address

1200 N ELM ST
GREENSBORO NC
27401-1004
US

V. Phone/Fax

Practice location:
  • Phone: 336-832-8060
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1912
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: