Provider Demographics
NPI:1720473606
Name:WYNN, WILLIAM
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:
Last Name:WYNN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4127 HWY 6
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77478
Mailing Address - Country:US
Mailing Address - Phone:480-514-7886
Mailing Address - Fax:
Practice Address - Street 1:4127 HWY 6
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77478
Practice Address - Country:US
Practice Address - Phone:480-514-7886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-30
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNV20111453781101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1982975009Medicaid
NV1720473606Medicaid