Provider Demographics
NPI:1669612917
Name:WYNN, HEATHER ANNE (LMHC)
Entity type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:ANNE
Last Name:WYNN
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:MRS
Other - First Name:HEATHER
Other - Middle Name:WYNN
Other - Last Name:RANDALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMHC
Mailing Address - Street 1:9220 BONITA BEACH RD SE STE 200
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34135-4231
Mailing Address - Country:US
Mailing Address - Phone:239-537-2236
Mailing Address - Fax:239-677-3025
Practice Address - Street 1:9220 BONITA BEACH RD SE STE 200
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34135-4231
Practice Address - Country:US
Practice Address - Phone:239-537-2236
Practice Address - Fax:239-677-3025
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-26
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
FLMH10531101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health