Provider Demographics
NPI:1265731913
Name:WYNNE, KARIN (LCSW)
Entity type:Individual
Prefix:
First Name:KARIN
Middle Name:
Last Name:WYNNE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 S FULLERTON AVE
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-3455
Mailing Address - Country:US
Mailing Address - Phone:973-744-4494
Mailing Address - Fax:973-744-4492
Practice Address - Street 1:31 S FULLERTON AVE
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-3455
Practice Address - Country:US
Practice Address - Phone:973-744-4494
Practice Address - Fax:973-744-4492
Is Sole Proprietor?:No
Enumeration Date:2011-03-21
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC053665001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical