Provider Demographics
NPI:1285158907
Name:WYATT, JULIE ANNA (BA MS)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:ANNA
Last Name:WYATT
Suffix:
Gender:F
Credentials:BA MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5704 PAMPUS LN
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71112-4953
Mailing Address - Country:US
Mailing Address - Phone:318-469-9681
Mailing Address - Fax:
Practice Address - Street 1:2924 KNIGHT ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-2415
Practice Address - Country:US
Practice Address - Phone:318-631-1122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-03
Last Update Date:2017-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health