Healthcare Provider Details

I. General information

NPI: 1053625053
Provider Name (Legal Business Name): KEITHA DONELLE WYATT LCSW, C-SSWS, BHRS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2010
Last Update Date: 04/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 N CLASSEN BLVD SUITE 233
OKLAHOMA CITY OK
73118-4627
US

IV. Provider business mailing address

1809 RASHEED RD
EDMOND OK
73003-3809
US

V. Phone/Fax

Practice location:
  • Phone: 405-242-5031
  • Fax:
Mailing address:
  • Phone: 405-340-6886
  • Fax: 405-340-6886

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number3971
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number3971
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: