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General NPI Number Information
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NPI Number | 1912417601
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Entity Type | Organization
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Legal Business Name | AMANDA M. WYATT, LLC
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Dates
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Enumeration Date | 10/06/2017
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Last Update Date | 10/06/2017
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Provider Practice Location Address
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Address Line | 2005 VALPARAISO ST STE 107
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City | VALPARAISO
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State | IN
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Zip | 46383-3330
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Country | US
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Telephone | 219-929-6205
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Fax |
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Provider Business Mailing Address
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Address Line | 3205 CLAIRBORNE XING
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City | VALPARAISO
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State | IN
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Zip | 46385-2970
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Country | US
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Telephone | 219-929-6205
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | AMANDA M WYATT
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Credential | LMHC
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Telephone | 219-929-6205
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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 | 39001619A
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License Number State | IN
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