Provider Demographics
NPI:1346574910
Name:WYNN, ALICE FERN (MA)
Entity Type:Individual
Prefix:MRS
First Name:ALICE
Middle Name:FERN
Last Name:WYNN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1033 S MILLBROOK WAY
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-2056
Mailing Address - Country:US
Mailing Address - Phone:801-243-0539
Mailing Address - Fax:
Practice Address - Street 1:70 N MAIN ST
Practice Address - Street 2:SUITE 103
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-6101
Practice Address - Country:US
Practice Address - Phone:801-298-5222
Practice Address - Fax:801-294-0295
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-29
Last Update Date:2009-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6497798-6004101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional