Provider Demographics
NPI:1295012151
Name:WYNKOOP, CHARLES
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:WYNKOOP
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1370 NW FALLS CREEK LOOP
Mailing Address - Street 2:APT. 102
Mailing Address - City:OAK HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98277-3835
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:105 N W 1ST STREET
Practice Address - Street 2:
Practice Address - City:COUPEVILLE
Practice Address - State:WA
Practice Address - Zip Code:98239
Practice Address - Country:US
Practice Address - Phone:360-678-5555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-07
Last Update Date:2011-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60251516101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor