MEDICARE: SUSAN WYANT

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	:	1992274468
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN WYANT

Provider Business Mailing Address
First Line	:	10601 S WESTERN AVE STE 110
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73170-6215
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	10601 S WESTERN AVE STE 110
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73170-6215
Country	:	US
Telephone Number	:	405-703-4423
Fax Number	:	405-703-4499

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

Provider Enumeration Date	:	11/14/2018
Last Update Date	:	11/14/2018

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Directions to “ SUSAN WYANT ” Practice Location

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