MEDICARE: BEREVON TAYSHAWN WYATT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	14485-146	WI

General Provider Information

NPI Number	:	1114526068
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BEREVON TAYSHAWN WYATT

Provider Business Mailing Address
First Line	:	1727 W KEEFE AVE
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53206-2322
Country	:	US
Telephone Number	:	414-915-4213
Fax Number	:

Provider Business Practice Location Address
First Line	:	3510 N OAKLAND AVE STE 206
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53211-2746
Country	:	US
Telephone Number	:	414-915-4213
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/21/2020
Last Update Date	:	10/21/2020

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Directions to “ BEREVON TAYSHAWN WYATT ” Practice Location

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