Provider Demographics
NPI:1275803975
Name:WYNN, TAMARA W
Entity Type:Individual
Prefix:MS
First Name:TAMARA
Middle Name:W
Last Name:WYNN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14650 DETROIT AVENUE
Mailing Address - Street 2:SUITE LL40
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107
Mailing Address - Country:US
Mailing Address - Phone:216-226-2721
Mailing Address - Fax:216-226-2731
Practice Address - Street 1:14650 DETROIT AVENUE
Practice Address - Street 2:SUITE LL40
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107
Practice Address - Country:US
Practice Address - Phone:216-226-2721
Practice Address - Fax:216-226-2731
Is Sole Proprietor?:No
Enumeration Date:2012-01-11
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH071041101YA0400X
OHI00025211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)