Provider Demographics
NPI:1669147864
Name:WYNN, ANTERIA RUTH MARIE (CADC)
Entity type:Individual
Prefix:
First Name:ANTERIA
Middle Name:RUTH MARIE
Last Name:WYNN
Suffix:
Gender:F
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 SPRINGSIDE RD APT C3
Mailing Address - Street 2:
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28803-3475
Mailing Address - Country:US
Mailing Address - Phone:828-577-3902
Mailing Address - Fax:
Practice Address - Street 1:6 ROBERTS RD
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28803-8699
Practice Address - Country:US
Practice Address - Phone:800-805-6989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-11
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCCADC-27646101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)