Healthcare Provider Details

I. General information

NPI: 1134172562
Provider Name (Legal Business Name): STEVEN CHARLES WYATT PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 05/30/2020
Certification Date: 05/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9041 EXECUTIVE PARK DR SUITE 210
KNOXVILLE TN
37923-4621
US

IV. Provider business mailing address

9041 EXECUTIVE PARK DR SUITE 210
KNOXVILLE TN
37923-4621
US

V. Phone/Fax

Practice location:
  • Phone: 865-603-2192
  • Fax: 865-381-0544
Mailing address:
  • Phone: 865-603-2192
  • Fax: 865-381-0544

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberP2708
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2708
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: