Basic Information
Provider Information | |||||||||
NPI: | 1144207721 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WYATT | ||||||||
FirstName: | CYNTHIA | ||||||||
MiddleName: | ANN MILLER | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7206 FLOWERING ALMOND DR | ||||||||
Address2: |   | ||||||||
City: | COLORADO SPRINGS | ||||||||
State: | CO | ||||||||
PostalCode: | 809235499 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9403371550 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 100 W ENT AVE | ||||||||
Address2: | BUILDING 725 | ||||||||
City: | PETERSON SPACE FORCE BASE | ||||||||
State: | CO | ||||||||
PostalCode: | 80916 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7195568943 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/27/2005 | ||||||||
LastUpdateDate: | 08/31/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/29/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 989226 | CO | N |   | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 8441 | LA | N |   | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 41874 | TX | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.