Basic Information
| Provider Information | |||||||||
| NPI: | 1528671336 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WIATT | ||||||||
| FirstName: | TRISHA | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MA, LAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2153 E JOYCE BLVD STE 201 | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727035285 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4795759471 | ||||||||
| FaxNumber: | 4795879392 | ||||||||
| Practice Location | |||||||||
| Address1: | 114 E CRANDALL AVE STE B | ||||||||
| Address2: | |||||||||
| City: | HARRISON | ||||||||
| State: | AR | ||||||||
| PostalCode: | 726013628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8707418484 | ||||||||
| FaxNumber: | 8707414088 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2020 | ||||||||
| LastUpdateDate: | 03/16/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | A2009114 | AR | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.