Provider Demographics
NPI:1336406024
Name:WYNN, SALLY (SUDCC IV-CS)
Entity Type:Individual
Prefix:DR
First Name:SALLY
Middle Name:
Last Name:WYNN
Suffix:
Gender:F
Credentials:SUDCC IV-CS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3882 STILLMAN PARK CIR SPC 41
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95824-3666
Mailing Address - Country:US
Mailing Address - Phone:916-317-4464
Mailing Address - Fax:916-970-5091
Practice Address - Street 1:2100 CAPITOL AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-5721
Practice Address - Country:US
Practice Address - Phone:916-317-4464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-18
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAW0702211501101YA0400X
CA5940101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5940OtherCALIFORNIA ASSOCIATION OF DUI TREATMENT PROGRAMS
CAW0702211501OtherBREINING - MASTERS LEVEL REGISTERED ADDICTION SPECIALIST