Provider Demographics
NPI:1356436653
Name:WYNN, KRISTINA GAY (LCSW,CADC,RN)
Entity type:Individual
Prefix:MRS
First Name:KRISTINA
Middle Name:GAY
Last Name:WYNN
Suffix:
Gender:F
Credentials:LCSW,CADC,RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:390 E. BETHEL
Mailing Address - Street 2:
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914
Mailing Address - Country:US
Mailing Address - Phone:708-936-0778
Mailing Address - Fax:
Practice Address - Street 1:5320 159TH STREET
Practice Address - Street 2:SUITE 100
Practice Address - City:OAK FOREST
Practice Address - State:IL
Practice Address - Zip Code:60452
Practice Address - Country:US
Practice Address - Phone:708-717-0191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL5573101YA0400X
IL101YP2500X, 163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health