Provider Demographics
NPI:1053625053
Name:WYATT, KEITHA DONELLE (LCSW, C-SSWS, BHRS)
Entity type:Individual
Prefix:MRS
First Name:KEITHA
Middle Name:DONELLE
Last Name:WYATT
Suffix:
Gender:F
Credentials:LCSW, C-SSWS, BHRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1809 RASHEED RD
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73003-3809
Mailing Address - Country:US
Mailing Address - Phone:405-340-6886
Mailing Address - Fax:405-340-6886
Practice Address - Street 1:4801 N CLASSEN BLVD
Practice Address - Street 2:SUITE 233
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73118-4627
Practice Address - Country:US
Practice Address - Phone:405-242-5031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-02
Last Update Date:2011-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK39711041C0700X, 1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool