Provider Demographics
NPI:1598439747
Name:WYNN, ELISHA (LCSW)
Entity Type:Individual
Prefix:MR
First Name:ELISHA
Middle Name:
Last Name:WYNN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 FRUIT ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-2621
Mailing Address - Country:US
Mailing Address - Phone:617-724-5341
Mailing Address - Fax:617-726-1042
Practice Address - Street 1:55 FRUIT ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2621
Practice Address - Country:US
Practice Address - Phone:617-724-5341
Practice Address - Fax:617-726-1042
Is Sole Proprietor?:No
Enumeration Date:2021-08-02
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0002246851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical