Healthcare Provider Details

I. General information

NPI: 1568972552
Provider Name (Legal Business Name): MARIAH MERCEDES WYATT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2017
Last Update Date: 09/08/2020
Certification Date: 09/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9300 NE OAK VIEW DR
VANCOUVER WA
98662-6157
US

IV. Provider business mailing address

117 NW TRINITY PL APT 1
PORTLAND OR
97209-1929
US

V. Phone/Fax

Practice location:
  • Phone: 360-567-2211
  • Fax:
Mailing address:
  • Phone: 503-508-4848
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: