Provider Demographics
NPI:1164859989
Name:WYNN, DAVID (LCSW)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:
Last Name:WYNN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-367-2175
Mailing Address - Fax:208-376-0285
Practice Address - Street 1:131 N ALLUMBAUGH ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9204
Practice Address - Country:US
Practice Address - Phone:208-367-2175
Practice Address - Fax:208-376-0285
Is Sole Proprietor?:No
Enumeration Date:2013-10-11
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW - 332561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical