Provider Demographics
NPI:1225404437
Name:WYNN, TIFFANY (LPCC)
Entity Type:Individual
Prefix:DR
First Name:TIFFANY
Middle Name:
Last Name:WYNN
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 MENAUL BLVD NW # 2360
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-1322
Mailing Address - Country:US
Mailing Address - Phone:505-670-7765
Mailing Address - Fax:
Practice Address - Street 1:1524 BISHOPS LODGE RD
Practice Address - Street 2:#B
Practice Address - City:TESUQUE
Practice Address - State:NM
Practice Address - Zip Code:87506
Practice Address - Country:US
Practice Address - Phone:505-490-3547
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-12
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCCMH0203641101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM32475764Medicaid