MEDICARE: SANDRA KAYE WYATT M.S., CCC-SLP

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	235Z00000X	Speech-Language Pathologist	263	AR

General Provider Information

NPI Number	:	1881826949
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SANDRA KAYE WYATT M.S., CCC-SLP

Provider Business Mailing Address
First Line	:	PO BOX 24915
Second Line	:
City	:	LITTLE ROCK
State	:	AR
Zip	:	72221-4915
Country	:	US
Telephone Number	:	501-860-3500
Fax Number	:	800-661-8025

Provider Business Practice Location Address
First Line	:	8952 MARKET ST
Second Line	:	SUITE 7B
City	:	DOVER
State	:	AR
Zip	:	72837-9110
Country	:	US
Telephone Number	:	501-860-3500
Fax Number	:	800-661-8025

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

Provider Enumeration Date	:	08/21/2009
Last Update Date	:	05/04/2021

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