Provider Demographics
NPI:1720628167
Name:WYNN, SAMANTHA JOANN (SUDPT)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JOANN
Last Name:WYNN
Suffix:
Gender:F
Credentials:SUDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:934 S GARFIELD RD
Mailing Address - Street 2:
Mailing Address - City:AIRWAY HEIGHTS
Mailing Address - State:WA
Mailing Address - Zip Code:99001-9030
Mailing Address - Country:US
Mailing Address - Phone:509-447-7193
Mailing Address - Fax:
Practice Address - Street 1:808 COMMUNITY HALL RD
Practice Address - Street 2:
Practice Address - City:CUSICK
Practice Address - State:WA
Practice Address - Zip Code:99119-6034
Practice Address - Country:US
Practice Address - Phone:509-447-7193
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-14
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60982388101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)