MEDICARE: JOHNNIE L WYATT M.A.

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1871814491
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHNNIE L WYATT M.A.

Provider Business Mailing Address
First Line	:	10901 MACARTHUR BLVD
Second Line	:	STE #202
City	:	OAKLAND
State	:	CA
Zip	:	94605-5200
Country	:	US
Telephone Number	:	510-430-1115
Fax Number	:	510-430-1116

Provider Business Practice Location Address
First Line	:	10901 MACARTHUR BLVD
Second Line	:	STE #202
City	:	OAKLAND
State	:	CA
Zip	:	94605-5200
Country	:	US
Telephone Number	:	510-430-1115
Fax Number	:	510-430-1116

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

Provider Enumeration Date	:	06/17/2010
Last Update Date	:	06/17/2010

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