Provider Demographics
NPI:1467881334
Name:WYNN, STEPHVANIE (LPC, PHD, IOP)
Entity type:Individual
Prefix:
First Name:STEPHVANIE
Middle Name:
Last Name:WYNN
Suffix:
Gender:F
Credentials:LPC, PHD, IOP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15331 W BELL RD STE 212
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-4104
Mailing Address - Country:US
Mailing Address - Phone:623-439-5770
Mailing Address - Fax:
Practice Address - Street 1:15331 W BELL RD STE 212
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-4104
Practice Address - Country:US
Practice Address - Phone:623-439-5770
Practice Address - Fax:623-249-3350
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-01
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401007672101YP2500X
AZ18488101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional