Healthcare Provider Details

I. General information

NPI: 1902206212
Provider Name (Legal Business Name): PATRICE WYATT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2014
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 BROAD ROCK BLVD
RICHMOND VA
23224-4915
US

IV. Provider business mailing address

1201 BROAD ROCK BLVD # 652122
RICHMOND VA
23249-0001
US

V. Phone/Fax

Practice location:
  • Phone: 804-675-6342
  • Fax:
Mailing address:
  • Phone: 804-675-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0903002027
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: