Provider Demographics
NPI:1679074082
Name:WYRICK, MICHAEL E (PHD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:E
Last Name:WYRICK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1420 LONGVIEW DR
Mailing Address - Street 2:
Mailing Address - City:BOONEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72927-3830
Mailing Address - Country:US
Mailing Address - Phone:479-675-6392
Mailing Address - Fax:
Practice Address - Street 1:1420 LONGVIEW DR
Practice Address - Street 2:
Practice Address - City:BOONEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72927-3830
Practice Address - Country:US
Practice Address - Phone:479-675-6392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-22
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR80-15P103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral