Provider Demographics
NPI:1851540702
Name:WYNER, GARRET BENJAMIN (PHD, PSYD)
Entity Type:Individual
Prefix:DR
First Name:GARRET
Middle Name:BENJAMIN
Last Name:WYNER
Suffix:
Gender:M
Credentials:PHD, PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12944 GREENLEAF ST
Mailing Address - Street 2:
Mailing Address - City:STUDIO CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91604-2224
Mailing Address - Country:US
Mailing Address - Phone:818-784-4784
Mailing Address - Fax:818-784-7922
Practice Address - Street 1:12944 GREENLEAF ST
Practice Address - Street 2:
Practice Address - City:STUDIO CITY
Practice Address - State:CA
Practice Address - Zip Code:91604-2224
Practice Address - Country:US
Practice Address - Phone:818-784-4784
Practice Address - Fax:818-784-7922
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-16
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225400000X
CA27475103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner