Provider Demographics
NPI:1407654742
Name:WYATT, LORENZA LAMONT
Entity type:Individual
Prefix:
First Name:LORENZA
Middle Name:LAMONT
Last Name:WYATT
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1509 NATHAN HUNT RD
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27410-3309
Mailing Address - Country:US
Mailing Address - Phone:804-243-0663
Mailing Address - Fax:
Practice Address - Street 1:411 DOLLEY MADISON RD
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27410-5142
Practice Address - Country:US
Practice Address - Phone:336-663-6570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-04
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA21135101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health