Provider Demographics
NPI:1164977690
Name:WYNN, S KELLY KAY (LCSW)
Entity Type:Individual
Prefix:
First Name:S KELLY
Middle Name:KAY
Last Name:WYNN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3021 RIDGE RD
Mailing Address - Street 2:STE A19
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75032-5806
Mailing Address - Country:US
Mailing Address - Phone:310-749-6568
Mailing Address - Fax:
Practice Address - Street 1:3021 RIDGE RD
Practice Address - Street 2:STE A19
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75032-5806
Practice Address - Country:US
Practice Address - Phone:310-749-6568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-25
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX623431041C0700X
CA206401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical