Provider Demographics
NPI:1609359389
Name:D.A. WYNNE & ASSOCIATES,INC.
Entity Type:Organization
Organization Name:D.A. WYNNE & ASSOCIATES,INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:C
Authorized Official - Last Name:KRUEGER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-C, MPH
Authorized Official - Phone:301-439-6700
Mailing Address - Street 1:11900 PARKLAWN DR STE 120
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-2668
Mailing Address - Country:US
Mailing Address - Phone:301-468-5663
Mailing Address - Fax:
Practice Address - Street 1:11900 PARKLAWN DR STE 120
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20852-2668
Practice Address - Country:US
Practice Address - Phone:301-468-5663
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:D.A. WYNNE & ASSOCIATES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-09-10
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1457474017Medicaid
MD1700363223Medicaid