Provider Demographics
NPI:1174771505
Name:CARSON, WYATT DANE (PLADC)
Entity type:Individual
Prefix:MR
First Name:WYATT
Middle Name:DANE
Last Name:CARSON
Suffix:
Gender:M
Credentials:PLADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:322 NORRIS AVE
Mailing Address - Street 2:#5
Mailing Address - City:MC COOK
Mailing Address - State:NE
Mailing Address - Zip Code:69001-3700
Mailing Address - Country:US
Mailing Address - Phone:308-345-5592
Mailing Address - Fax:
Practice Address - Street 1:322 NORRIS AVE
Practice Address - Street 2:#5
Practice Address - City:MC COOK
Practice Address - State:NE
Practice Address - Zip Code:69001-3700
Practice Address - Country:US
Practice Address - Phone:308-345-5592
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-27
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NEP-628101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)