Provider Demographics
NPI:1215794870
Name:WYATT, BENJAMIN KEITH (MA, CMHC)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:KEITH
Last Name:WYATT
Suffix:
Gender:M
Credentials:MA, CMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:921 E 86TH ST STE 210
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46240-1841
Mailing Address - Country:US
Mailing Address - Phone:812-568-3641
Mailing Address - Fax:
Practice Address - Street 1:921 E 86TH ST STE 210
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46240-1841
Practice Address - Country:US
Practice Address - Phone:812-568-3641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-29
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99123609A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health