Provider Demographics
NPI:1528671336
Name:WIATT, TRISHA D (MA, LAC)
Entity type:Individual
Prefix:
First Name:TRISHA
Middle Name:D
Last Name:WIATT
Suffix:
Gender:F
Credentials:MA, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2153 E JOYCE BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-5285
Mailing Address - Country:US
Mailing Address - Phone:479-575-9471
Mailing Address - Fax:479-587-9392
Practice Address - Street 1:114 E CRANDALL AVE STE B
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:AR
Practice Address - Zip Code:72601-3628
Practice Address - Country:US
Practice Address - Phone:870-741-8484
Practice Address - Fax:870-741-4088
Is Sole Proprietor?:No
Enumeration Date:2020-08-31
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA2009114101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional