NPI 1114526068

Berevon Tayshawn Wyatt

Practitioner Massage Therapist Milwaukee, WI

Practice location

Address: 3510 N Oakland Ave STE 206, Milwaukee, WI 53211-2746
Phone: (414) 915-4213
Mailing address: 1727 W Keefe Ave, Milwaukee, WI 53206-2322

Registered specialties

Massage Therapist Primary

Respiratory, Developmental, Rehabilitative and Restorative Service Providers Taxonomy 225700000X Licence 14485-146 (WI)

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Registry record

NPI: 1114526068
Entity type: Individual
Sex (as registered): Male
NPI issued: 21 Oct 2020
Record last updated: 21 Oct 2020

Reproduced from NPPES, the federal provider registry. The date above is when the provider last updated their own entry, not when we fetched it - a record can be years old and still current in the registry.