Provider Demographics
NPI:1942736772
Name:MARTIN, WYNN LESLIE (CSW, CIT)
Entity Type:Individual
Prefix:MR
First Name:WYNN
Middle Name:LESLIE
Last Name:MARTIN
Suffix:
Gender:M
Credentials:CSW, CIT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4150 EARHART BLVD
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70125-1955
Mailing Address - Country:US
Mailing Address - Phone:504-821-7287
Mailing Address - Fax:504-821-7296
Practice Address - Street 1:4150 EARHART BLVD
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70125-1955
Practice Address - Country:US
Practice Address - Phone:504-821-7289
Practice Address - Fax:504-821-7296
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1386916880Medicaid