Provider Demographics
NPI:1285027003
Name:WYATT, LARRY SHANE (LPC)
Entity type:Individual
Prefix:MR
First Name:LARRY
Middle Name:SHANE
Last Name:WYATT
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:261 YVONNE AVE
Mailing Address - Street 2:
Mailing Address - City:CROSSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38555-4735
Mailing Address - Country:US
Mailing Address - Phone:931-456-2859
Mailing Address - Fax:931-707-8921
Practice Address - Street 1:261 YVONNE AVE
Practice Address - Street 2:
Practice Address - City:CROSSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38555-4735
Practice Address - Country:US
Practice Address - Phone:931-456-2859
Practice Address - Fax:931-707-8921
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-18
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3239101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional