Provider Demographics
NPI:1023765211
Name:WYATT, ANTOINETTE CHERYL
Entity type:Individual
Prefix:MS
First Name:ANTOINETTE
Middle Name:CHERYL
Last Name:WYATT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:351 N NEW HAMPSHIRE AVE APT 503
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:08401-2975
Mailing Address - Country:US
Mailing Address - Phone:917-743-6760
Mailing Address - Fax:
Practice Address - Street 1:351 N NEW HAMPSHIRE AVE APT 503
Practice Address - Street 2:
Practice Address - City:ATLANTIC CITY
Practice Address - State:NJ
Practice Address - Zip Code:08401-2975
Practice Address - Country:US
Practice Address - Phone:917-743-6760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-07
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY083349-01104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker