Provider Demographics
NPI:1346371432
Name:WYNNE, SUSAN (MSW, LCSW)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:
Last Name:WYNNE
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11307 LEMOLI AVE
Mailing Address - Street 2:# 5
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90303-2800
Mailing Address - Country:US
Mailing Address - Phone:310-671-9810
Mailing Address - Fax:
Practice Address - Street 1:3761 STOCKER ST
Practice Address - Street 2:211
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90008-5111
Practice Address - Country:US
Practice Address - Phone:323-295-2060
Practice Address - Fax:323-295-2954
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALSC 205771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical