Provider Demographics
NPI:1275673311
Name:WYNNE, HILARY J (CCC-A)
Entity Type:Individual
Prefix:
First Name:HILARY
Middle Name:J
Last Name:WYNNE
Suffix:
Gender:F
Credentials:CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 ELM ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01609-2541
Mailing Address - Country:US
Mailing Address - Phone:508-757-0330
Mailing Address - Fax:508-754-9426
Practice Address - Street 1:48 ELM ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01609-2541
Practice Address - Country:US
Practice Address - Phone:508-757-0330
Practice Address - Fax:508-754-9426
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA759231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAAD 0178OtherBLUE CROSS
MAWY 041764Medicare ID - Type Unspecified