Provider Demographics
NPI:1992345011
Name:WYATT, CONNIE COLLEEN (OTR/L)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:COLLEEN
Last Name:WYATT
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4815 SHARPE RD
Mailing Address - Street 2:
Mailing Address - City:ANACORTES
Mailing Address - State:WA
Mailing Address - Zip Code:98221-8403
Mailing Address - Country:US
Mailing Address - Phone:360-770-1752
Mailing Address - Fax:
Practice Address - Street 1:4815 SHARPE RD
Practice Address - Street 2:
Practice Address - City:ANACORTES
Practice Address - State:WA
Practice Address - Zip Code:98221-8403
Practice Address - Country:US
Practice Address - Phone:360-770-1752
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-07
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60850227225XG0600X, 225XP0019X, 225XE0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XE0001XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistEnvironmental Modification
No225XG0600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGerontology
No225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA60850227OtherOCCUPATIONAL THERAPIST LICENSE