Provider Demographics
NPI:1679068324
Name:WYATT, LARRY (LPC)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:WYATT
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1495 WATERCOVE LN
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-7041
Mailing Address - Country:US
Mailing Address - Phone:770-995-9789
Mailing Address - Fax:770-995-9787
Practice Address - Street 1:4037 DARLING CT SW STE B
Practice Address - Street 2:
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-2365
Practice Address - Country:US
Practice Address - Phone:770-995-9789
Practice Address - Fax:770-995-9787
Is Sole Proprietor?:No
Enumeration Date:2018-06-26
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC008237101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional