Provider Demographics
NPI:1851456792
Name:WYNN, CAROLYN (LCSW, LMFT)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:WYNN
Suffix:
Gender:F
Credentials:LCSW, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4625 LILLIAN ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77007-5544
Mailing Address - Country:US
Mailing Address - Phone:888-844-6289
Mailing Address - Fax:281-364-1827
Practice Address - Street 1:4625 LILLIAN ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77007-5544
Practice Address - Country:US
Practice Address - Phone:888-844-6289
Practice Address - Fax:281-364-1827
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX123031041C0700X
TX1371106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist