Provider Demographics
NPI:1124142989
Name:WYATT, BEVERLY JEAN (MSW,LSW)
Entity type:Individual
Prefix:MRS
First Name:BEVERLY
Middle Name:JEAN
Last Name:WYATT
Suffix:
Gender:F
Credentials:MSW,LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RRT 10 MAIN STREET
Mailing Address - Street 2:P.O. BOX 123
Mailing Address - City:PINEVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:24874-0123
Mailing Address - Country:US
Mailing Address - Phone:304-732-9132
Mailing Address - Fax:304-732-6589
Practice Address - Street 1:RRT 10 MAIN STREET
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:WV
Practice Address - Zip Code:24874-0123
Practice Address - Country:US
Practice Address - Phone:304-732-9132
Practice Address - Fax:304-732-6589
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAP00939569104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker