Basic Information
| Provider Information | |||||||||
| NPI: | 1700261104 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WYATT | ||||||||
| FirstName: | WANDA | ||||||||
| MiddleName: | LOU | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | MFTI | ||||||||
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| Mailing Information | |||||||||
| Address1: | 313 W 228TH ST | ||||||||
| Address2: | |||||||||
| City: | CARSON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907453612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103206228 | ||||||||
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| Practice Location | |||||||||
| Address1: | 901 N PACIFIC COAST HWY STE A | ||||||||
| Address2: | |||||||||
| City: | REDONDO BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902772162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103161610 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2015 | ||||||||
| LastUpdateDate: | 08/03/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | IMF76128 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.