Provider Demographics
NPI:1124071378
Name:WYATT, CHARLES L (MDIV)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:L
Last Name:WYATT
Suffix:
Gender:M
Credentials:MDIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:478 GREGORY RD
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:NC
Mailing Address - Zip Code:28734-7136
Mailing Address - Country:US
Mailing Address - Phone:828-524-3040
Mailing Address - Fax:
Practice Address - Street 1:478 GREGORY RD
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:NC
Practice Address - Zip Code:28734-7136
Practice Address - Country:US
Practice Address - Phone:828-524-3040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2501101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional