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General NPI Number Information
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NPI Number | 1134487713
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Entity Type | Individual
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Provider Name | GREGORY LOUIS WYATT LMHC
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Gender | Male
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Dates
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Enumeration Date | 05/02/2012
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Last Update Date | 05/02/2012
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Provider Practice Location Address
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Address Line | 6622 BANBURY RD
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City | JACKSONVILLE
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State | FL
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Zip | 32266
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Country | US
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Telephone | 904-743-8258
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Fax |
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Provider Business Mailing Address
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Address Line | 6622 BANBURY RD.
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City | JACKSONVILLE
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State | FL
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Zip | 32211
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Country | US
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Telephone | 904-743-8258
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | MH6521
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License Number State | FL
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