Provider Demographics
NPI:1326285545
Name:RA, WYNEMA MARIE (LPC, LADC)
Entity Type:Individual
Prefix:MS
First Name:WYNEMA
Middle Name:MARIE
Last Name:RA
Suffix:
Gender:F
Credentials:LPC, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6404 WESTLANE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73142-4420
Mailing Address - Country:US
Mailing Address - Phone:405-720-2476
Mailing Address - Fax:
Practice Address - Street 1:6404 WESTLANE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73142-4420
Practice Address - Country:US
Practice Address - Phone:405-720-2476
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-09
Last Update Date:2009-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK260101YA0400X
OK2692101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)