Provider Demographics
NPI:1881226173
Name:WYNN, SHELBY M (ATR, LPC)
Entity Type:Individual
Prefix:MISS
First Name:SHELBY
Middle Name:M
Last Name:WYNN
Suffix:
Gender:F
Credentials:ATR, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1942 FAIRHOPE RD NW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24017-1708
Mailing Address - Country:US
Mailing Address - Phone:540-815-3644
Mailing Address - Fax:
Practice Address - Street 1:1942 FAIRHOPE RD NW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24017-1708
Practice Address - Country:US
Practice Address - Phone:540-815-3644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-05
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0704007013101YM0800X
VA0701010054101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health