Provider Demographics
NPI:1841753993
Name:WYNN, LAURA (MSW)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:WYNN
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 MACDONOUGH ST # 3
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11216-2507
Mailing Address - Country:US
Mailing Address - Phone:205-243-9035
Mailing Address - Fax:
Practice Address - Street 1:1824 MADISON AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10035-3832
Practice Address - Country:US
Practice Address - Phone:212-423-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-06
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1077351041C0700X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical