Provider Demographics
NPI:1316393499
Name:EDLUND-WYNN, SOFIA
Entity Type:Individual
Prefix:
First Name:SOFIA
Middle Name:
Last Name:EDLUND-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 1:75 SOCKANOSSET CROSS RD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02920-5558
Mailing Address - Country:US
Mailing Address - Phone:401-415-8868
Mailing Address - Fax:401-415-8880
Practice Address - Street 1:75 SOCKANOSSET CROSS RD
Practice Address - Street 2:SUITE 301
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02920-5558
Practice Address - Country:US
Practice Address - Phone:401-415-8868
Practice Address - Fax:401-415-8880
Is Sole Proprietor?:No
Enumeration Date:2016-05-09
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMHC00786101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health