Provider Demographics
NPI:1851335368
Name:WYNNE, THOMAS W (LCSW)
Entity Type:Individual
Prefix:PROF
First Name:THOMAS
Middle Name:W
Last Name:WYNNE
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:PO BOX 50521
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79710-0521
Mailing Address - Country:US
Mailing Address - Phone:432-599-1727
Mailing Address - Fax:
Practice Address - Street 1:6 DESTA DR
Practice Address - Street 2:SUITE 2640
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79705-5520
Practice Address - Country:US
Practice Address - Phone:432-599-1727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX173811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX132197802Medicaid
TX00980HMedicare ID - Type Unspecified