Healthcare Provider Details

I. General information

NPI: 1477939460
Provider Name (Legal Business Name): KATHY DIANE WYRICK LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2015
Last Update Date: 10/24/2024
Certification Date: 10/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

616 HARRISON ST
PRINCETON WV
24740-3141
US

IV. Provider business mailing address

533 MISTY HILLS DR
PRINCETON WV
24739-6453
US

V. Phone/Fax

Practice location:
  • Phone: 304-487-3487
  • Fax: 681-282-5441
Mailing address:
  • Phone: 304-320-0498
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1868
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: