Provider Demographics
NPI:1194269019
Name:WYATT, KIMBERLY SAPHAIRE-DAWN (AAC, BA)
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:SAPHAIRE-DAWN
Last Name:WYATT
Suffix:
Gender:F
Credentials:AAC, BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 MILWAUKEE ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98273
Mailing Address - Country:US
Mailing Address - Phone:360-419-7574
Mailing Address - Fax:360-428-4354
Practice Address - Street 1:209 MILWAUKEE ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273
Practice Address - Country:US
Practice Address - Phone:360-419-7574
Practice Address - Fax:360-428-4354
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-12
Last Update Date:2020-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG 60687237101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor