Provider Demographics
NPI:1629774187
Name:WYNENS, COURTNEY MAYTON (MED,CCC-SLP)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:MAYTON
Last Name:WYNENS
Suffix:
Gender:F
Credentials:MED,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3746 OLD VINE WAY
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31605-7958
Mailing Address - Country:US
Mailing Address - Phone:706-399-3644
Mailing Address - Fax:
Practice Address - Street 1:3354 GREYSTONE WAY
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31605-1096
Practice Address - Country:US
Practice Address - Phone:229-244-3552
Practice Address - Fax:229-244-7030
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-06
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP011261235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist