Provider Demographics
NPI:1194877068
Name:WHEAT, DARRYL (LCSW)
Entity type:Individual
Prefix:DR
First Name:DARRYL
Middle Name:
Last Name:WHEAT
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 WOODGATE DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39042-2285
Mailing Address - Country:US
Mailing Address - Phone:601-613-5250
Mailing Address - Fax:601-824-7775
Practice Address - Street 1:106 OFFICE PARK DR STE D
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39042-2404
Practice Address - Country:US
Practice Address - Phone:601-613-5250
Practice Address - Fax:601-824-7775
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC14901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00114348Medicaid