Provider Demographics
NPI:1235373416
Name:WYNN, CATHY YVONNE (MT019073)
Entity Type:Individual
Prefix:MISS
First Name:CATHY
Middle Name:YVONNE
Last Name:WYNN
Suffix:
Gender:F
Credentials:MT019073
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 OWENS RD LOT 506
Mailing Address - Street 2:
Mailing Address - City:WHITE OAK
Mailing Address - State:TX
Mailing Address - Zip Code:75693
Mailing Address - Country:US
Mailing Address - Phone:903-736-2969
Mailing Address - Fax:
Practice Address - Street 1:1109 EVERGREEN ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75604-2130
Practice Address - Country:US
Practice Address - Phone:903-736-2969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-01
Last Update Date:2009-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT019073225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXMT019073OtherMASSAGE THERAPIST