Active NPI
Elizabeth Blair Wyatt, PHD
- Clinical Psychologist
- Mentor, OH
National Provider Identifier
1285744276
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Psychologist
- License
- 4508
- Practice address
- 8039 Broadmoor Rd
#15
Mentor, OH 44060 - Phone
- (440) 269-1500
- Fax
- (440) 269-8545
- NPI assigned
- Aug 30, 2006
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Psychologist | 103TC0700X | 4508 | OH | Primary |
Addresses
Primary practice location
8039 Broadmoor Rd
#15
Mentor, OH 44060
Mailing address
8039 Broadmoor Rd
#15
Mentor, OH 44060
Phone (440) 269-1500
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 2065732 | Medicaid | OH |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Philosophy
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1156896000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1285744276",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "8039 BROADMOOR RD",
"address_2": "#15",
"city": "MENTOR",
"state": "OH",
"postal_code": "44060",
"telephone_number": "440-269-1500",
"fax_number": "440-269-8545"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "8039 BROADMOOR RD",
"address_2": "#15",
"city": "MENTOR",
"state": "OH",
"postal_code": "44060",
"telephone_number": "440-269-1500",
"fax_number": "440-269-8545"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WYATT",
"first_name": "ELIZABETH",
"middle_name": "BLAIR",
"name_prefix": "Dr.",
"credential": "PHD",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2006-08-30",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "103TC0700X",
"taxonomy_group": "",
"desc": "Psychologist, Clinical",
"state": "OH",
"license": "4508",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "2065732",
"state": "OH"
}
],
"endpoints": [],
"other_names": []
}Other providers in Mentor, OH
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.