Provider Demographics
NPI:1871814491
Name:WYATT, JOHNNIE L (MA)
Entity type:Individual
Prefix:
First Name:JOHNNIE
Middle Name:L
Last Name:WYATT
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10901 MACARTHUR BLVD
Mailing Address - Street 2:STE #202
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94605-5200
Mailing Address - Country:US
Mailing Address - Phone:510-430-1115
Mailing Address - Fax:510-430-1116
Practice Address - Street 1:10901 MACARTHUR BLVD
Practice Address - Street 2:STE #202
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94605-5200
Practice Address - Country:US
Practice Address - Phone:510-430-1115
Practice Address - Fax:510-430-1116
Is Sole Proprietor?:No
Enumeration Date:2010-06-17
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health