Provider Demographics
NPI:1801315361
Name:WYNN, SHAWNTEE NICOLE (LCSW)
Entity type:Individual
Prefix:MS
First Name:SHAWNTEE
Middle Name:NICOLE
Last Name:WYNN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9029 CLOISTERS E
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23229-4522
Mailing Address - Country:US
Mailing Address - Phone:804-767-0034
Mailing Address - Fax:
Practice Address - Street 1:5700 W GRACE ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-1832
Practice Address - Country:US
Practice Address - Phone:804-229-8416
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-15
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040075671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
1336699461OtherANTHEM AND AETNA