Provider Demographics
NPI:1871968107
Name:WYATT, TAMIKA S
Entity type:Individual
Prefix:
First Name:TAMIKA
Middle Name:S
Last Name:WYATT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1441
Mailing Address - Street 2:
Mailing Address - City:MONROVIA
Mailing Address - State:CA
Mailing Address - Zip Code:91017-1441
Mailing Address - Country:US
Mailing Address - Phone:626-790-9347
Mailing Address - Fax:
Practice Address - Street 1:3280 E FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91107-3103
Practice Address - Country:US
Practice Address - Phone:626-583-3450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-11
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF89561106H00000X
CA113711106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist