=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174545586
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEANNETTE B. WYATT MSS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1489 BALTIMORE PIKE BUILDING 200, SUITE 250
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19064-3958
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-544-2110
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 286 CONGRESS AVE
-----------------------------------------------------
City | LANSDOWNE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19050-1257
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-623-9610
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | CW013236
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------