Provider Demographics
NPI:1851672406
Name:WYNN, STEPHANIE MICHELE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:MICHELE
Last Name:WYNN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 S PARK VIS
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78628-2990
Mailing Address - Country:US
Mailing Address - Phone:813-470-9130
Mailing Address - Fax:
Practice Address - Street 1:216 S PARK VIS
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78628-2990
Practice Address - Country:US
Practice Address - Phone:813-470-9130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-08
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0088041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical