Provider Demographics
NPI:1003168832
Name:WYNIA, KIM (MFTI, CAS II, FAC)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:WYNIA
Suffix:
Gender:F
Credentials:MFTI, CAS II, FAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1422 E ARTESIA BLVD
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90805-1619
Mailing Address - Country:US
Mailing Address - Phone:562-733-7186
Mailing Address - Fax:562-423-0688
Practice Address - Street 1:1422 E ARTESIA BLVD
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90805-1619
Practice Address - Country:US
Practice Address - Phone:562-733-7186
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-03
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA76232101YM0800X
CA01-043373101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)