Provider Demographics
NPI:1285034249
Name:WYNNE, RENEE (LICSW)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:
Last Name:WYNNE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 PIEDMONT AVE
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55811-2915
Mailing Address - Country:US
Mailing Address - Phone:218-727-2696
Mailing Address - Fax:
Practice Address - Street 1:2900 PIEDMONT AVE
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55811-2915
Practice Address - Country:US
Practice Address - Phone:218-727-2696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-27
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN194781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical