Provider Demographics
NPI:1609239821
Name:MASSEY, WYATT J (PSYD)
Entity type:Individual
Prefix:DR
First Name:WYATT
Middle Name:J
Last Name:MASSEY
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 N FREEDOM BLVD
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-1677
Mailing Address - Country:US
Mailing Address - Phone:909-241-2619
Mailing Address - Fax:
Practice Address - Street 1:750 N FREEDOM BLVD
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-1677
Practice Address - Country:US
Practice Address - Phone:801-373-4760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-04
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041S0200X, 106S00000X
HIPSY-2208-0103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician