| Doctor Name: | MR. WYATT DANE CARSON |
| NPI Number: | 1174771505 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | PLADC |
| License Number: | P-628 |
| Business Practice Address: | 322 Norris Ave #5 Mc Cook, NE - 690013700 |
| Business Phone Number: | 3083455592 |
| Business Fax Number: | |
| Mailing Address: | 322 Norris Ave, #5 MC COOK |
| State: | NE |
| Postal Code: | 690013700 |
| Phone Number: | 3083455592 |
| Fax Number: | |
| NPI Enumeration Date: | 08/27/2008 |
| NPI Last Update Date: | 08/27/2008 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YA0400X |
| License Number: | P-628 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | NE |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Addiction (Substance Use Disorder) |
| Taxonomy Definition: | |