MEDICARE: ELIZABETH 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	106S00000X	Behavior Technician	RBT-25-423686	IN

General Provider Information

NPI Number	:	1902314024
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH WYATT

Provider Business Mailing Address
First Line	:	590 MISSOURI AVE STE 204
Second Line	:
City	:	JEFFERSONVILLE
State	:	IN
Zip	:	47130-3084
Country	:	US
Telephone Number	:	812-288-4688
Fax Number	:	812-610-8333

Provider Business Practice Location Address
First Line	:	590 MISSOURI AVE STE 204
Second Line	:
City	:	JEFFERSONVILLE
State	:	IN
Zip	:	47130-3084
Country	:	US
Telephone Number	:	812-288-4688
Fax Number	:	812-610-8333

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

Provider Enumeration Date	:	01/11/2018
Last Update Date	:	04/16/2025

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