MEDICARE: JOEL DANIEL WYATT MS

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	390200000X	Student in an Organized Health Care Education/Training Program
2	103TC0700X	Clinical Psychologist	071010570	IL

General Provider Information

NPI Number	:	1861983975
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOEL DANIEL WYATT MS

Provider Business Mailing Address
First Line	:	1645 W JACKSON BLVD STE 602
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60612-2847
Country	:	US
Telephone Number	:	312-942-8387
Fax Number	:

Provider Business Practice Location Address
First Line	:	1645 W JACKSON BLVD STE 602
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60612-2847
Country	:	US
Telephone Number	:	312-942-8387
Fax Number	:

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

Provider Enumeration Date	:	05/24/2018
Last Update Date	:	09/02/2021

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