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General NPI Number Information
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NPI Number | 1417731290
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Entity Type | Individual
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Provider Name | REX BLAIR WYATT LCSW
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Gender |
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Dates
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Enumeration Date | 08/22/2023
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Last Update Date | 09/16/2025
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Provider Practice Location Address
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Address Line | 520 N 4TH ST
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City | SPRINGFIELD
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State | IL
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Zip | 62702-5238
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Country | US
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Telephone | 217-545-8000
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Fax | 217-757-8161
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Provider Business Mailing Address
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Address Line | PO BOX 19639
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City | SPRINGFIELD
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State | IL
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Zip | 62794-9639
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Country | US
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Telephone | 217-545-8000
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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 | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 149.025823
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License Number State | IL
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