Healthcare Provider Details

I. General information

NPI: 1518519487
Provider Name (Legal Business Name): CHRISTOPHER M WYETH M.S., CCC-SLP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2019
Last Update Date: 03/17/2021
Certification Date: 03/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 BROAD ROCK BLVD
RICHMOND VA
23249-0001
US

IV. Provider business mailing address

1201 BROAD ROCK BLVD
RICHMOND VA
23249-0001
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2202008952
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: