Provider Demographics
NPI:1285744276
Name:WYATT, ELIZABETH BLAIR (PHD)
Entity type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:BLAIR
Last Name:WYATT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8039 BROADMOOR RD
Mailing Address - Street 2:#15
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060
Mailing Address - Country:US
Mailing Address - Phone:440-269-1500
Mailing Address - Fax:440-269-8545
Practice Address - Street 1:8039 BROADMOOR RD
Practice Address - Street 2:#15
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060
Practice Address - Country:US
Practice Address - Phone:440-269-1500
Practice Address - Fax:440-269-8545
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4508103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2065732Medicaid
OHCP18391Medicare ID - Type Unspecified