Healthcare Provider Details

I. General information

NPI: 1285027003
Provider Name (Legal Business Name): LARRY SHANE WYATT LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2015
Last Update Date: 03/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

261 YVONNE AVE
CROSSVILLE TN
38555-4735
US

IV. Provider business mailing address

261 YVONNE AVE
CROSSVILLE TN
38555-4735
US

V. Phone/Fax

Practice location:
  • Phone: 931-456-2859
  • Fax: 931-707-8921
Mailing address:
  • Phone: 931-456-2859
  • Fax: 931-707-8921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3239
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: