=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639034747
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WYATT WELLNESS AND CONSULTING, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/20/2025
-----------------------------------------------------
Last Update Date | 12/20/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2336 S 5TH ST
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62703-3410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-761-7709
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2336 S 5TH ST
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62703-3410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-761-7709
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LCSW
-----------------------------------------------------
Name | REX BLAIR WYATT
-----------------------------------------------------
Credential | MSW, LCSW
-----------------------------------------------------
Telephone | 217-761-7709
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------