Basic Information
| Provider Information | |||||||||
| NPI: | 1497872691 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WYANT | ||||||||
| FirstName: | TAMARA | ||||||||
| MiddleName: | WYNONA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | ASW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 921 W AVENUE J | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935343443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6613413052 | ||||||||
| FaxNumber: | 6617298912 | ||||||||
| Practice Location | |||||||||
| Address1: | 921 W AVENUE J | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935343443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6613413052 | ||||||||
| FaxNumber: | 6617298912 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2007 | ||||||||
| LastUpdateDate: | 11/25/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker | 101YM0800X | ASW25483 | CA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.