Provider Demographics
NPI:1104908334
Name:WYNNE, LOUIS (PHD)
Entity type:Individual
Prefix:DR
First Name:LOUIS
Middle Name:
Last Name:WYNNE
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 1:1420 CARLISLE BLVD NE
Mailing Address - Street 2:#109
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-5660
Mailing Address - Country:US
Mailing Address - Phone:505-280-4400
Mailing Address - Fax:505-897-4977
Practice Address - Street 1:1420 CARLISLE BLVD NE
Practice Address - Street 2:#109
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-5660
Practice Address - Country:US
Practice Address - Phone:505-280-4400
Practice Address - Fax:505-897-4977
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM140103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist