Provider Demographics
NPI:1427393842
Name:WYNNE, SARAH MICHELLE (MA, LPCC, NCC)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:MICHELLE
Last Name:WYNNE
Suffix:
Gender:F
Credentials:MA, LPCC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 49TH ST NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87105-1621
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3321 CANDELARIA RD NE STE 113
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-1969
Practice Address - Country:US
Practice Address - Phone:505-980-5932
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-11
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM101Y00000X
247200000X, 373H00000X
CMH0197821101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
No373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM57287244Medicaid