Basic Information
Provider Information
NPI: 1033557988
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: COLLETT
FirstName: RYAN
MiddleName: WYATT
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName: WYATT
OtherFirstName: RYAN
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType: 1
Mailing Information
Address1: 114 WYATT CIR
Address2:  
City: BATH SPRINGS
State: TN
PostalCode: 383111000
CountryCode: US
TelephoneNumber: 7315495841
FaxNumber:  
Practice Location
Address1: 524 W MAIN ST
Address2:  
City: DECATURVILLE
State: TN
PostalCode: 383298101
CountryCode: US
TelephoneNumber: 7318523591
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/12/2013
LastUpdateDate: 06/12/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225X00000X4244TNY Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist 

No ID Information.


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