Provider Demographics
NPI:1326731266
Name:WYNN, TYRESE LEE
Entity Type:Individual
Prefix:
First Name:TYRESE
Middle Name:LEE
Last Name:WYNN
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 1:1407 MULBERRY LN
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507-5330
Mailing Address - Country:US
Mailing Address - Phone:810-931-0238
Mailing Address - Fax:
Practice Address - Street 1:420 W 5TH AVE
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-2445
Practice Address - Country:US
Practice Address - Phone:810-257-3709
Practice Address - Fax:810-257-3755
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-26
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst