Provider Demographics
NPI:1013777036
Name:WYNN, MATTHEW JOHN (PHD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JOHN
Last Name:WYNN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11396
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94611-0396
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:539 BLAIR AVE
Practice Address - Street 2:
Practice Address - City:PIEDMONT
Practice Address - State:CA
Practice Address - Zip Code:94611-3734
Practice Address - Country:US
Practice Address - Phone:510-519-1928
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-19
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34922103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical