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General NPI Number Information
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NPI Number | 1861182008
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Entity Type | Individual
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Provider Name | ALLEGRA WYATT LMSW
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Gender | Female
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Dates
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Enumeration Date | 05/10/2023
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Last Update Date | 04/06/2025
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Provider Practice Location Address
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Address Line | 165 DEKALB INDUSTRIAL WAY STE G5
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City | DECATUR
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State | GA
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Zip | 30030-2204
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Country | US
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Telephone | 503-432-9432
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Fax |
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Provider Business Mailing Address
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Address Line | 165 DEKALB INDUSTRIAL WAY STE G5
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City | DECATUR
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State | GA
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Zip | 30030-2204
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Country | US
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Telephone | 503-432-9432
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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 | 104100000X
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Taxonomy Name | Social Worker
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License Number | MSW01156
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License Number State | GA
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