Provider Demographics
NPI:1215375563
Name:WYNN, QWENZELLA (LCAS-A)
Entity Type:Individual
Prefix:MISS
First Name:QWENZELLA
Middle Name:
Last Name:WYNN
Suffix:
Gender:F
Credentials:LCAS-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12640 SOUTHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LAURINBURG
Mailing Address - State:NC
Mailing Address - Zip Code:28352-8685
Mailing Address - Country:US
Mailing Address - Phone:910-318-8555
Mailing Address - Fax:
Practice Address - Street 1:12640 SOUTHWOOD DR
Practice Address - Street 2:
Practice Address - City:LAURINBURG
Practice Address - State:NC
Practice Address - Zip Code:28352
Practice Address - Country:US
Practice Address - Phone:910-318-8555
Practice Address - Fax:910-266-0093
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-10
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2884A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)