Provider Demographics
NPI:1386825057
Name:WYNNE, ELIZABETH M (LCSW)
Entity Type:Individual
Prefix:MISS
First Name:ELIZABETH
Middle Name:M
Last Name:WYNNE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 3RD ST NW
Mailing Address - Street 2:PO BOX 2055
Mailing Address - City:JAMESTOWN
Mailing Address - State:ND
Mailing Address - Zip Code:58402-2055
Mailing Address - Country:US
Mailing Address - Phone:701-253-6300
Mailing Address - Fax:701-253-6400
Practice Address - Street 1:520 3RD ST NW
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:ND
Practice Address - Zip Code:58401-2968
Practice Address - Country:US
Practice Address - Phone:701-253-6300
Practice Address - Fax:701-253-6400
Is Sole Proprietor?:No
Enumeration Date:2007-11-21
Last Update Date:2007-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND3089104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker