Provider Demographics
NPI:1225404437
Name:WYNN, TIFFANY (PHD, LPCC)
Entity type:Individual
Prefix:DR
First Name:TIFFANY
Middle Name:
Last Name:WYNN
Suffix:
Gender:F
Credentials:PHD, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 MENAUL BLVD NW # 2360
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-1322
Mailing Address - Country:US
Mailing Address - Phone:505-670-7765
Mailing Address - Fax:
Practice Address - Street 1:2727 SAN PEDRO DR NE STE 110
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-3373
Practice Address - Country:US
Practice Address - Phone:505-670-7765
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-12
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCCMH0203641101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM32475764Medicaid
NM66738342Medicaid