Provider Demographics
NPI:1811784697
Name:WYNN, KELSEY
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:WYNN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:
Other - Last Name:SCOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4503 WOODHALL WAY NE
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-1997
Mailing Address - Country:US
Mailing Address - Phone:470-216-0653
Mailing Address - Fax:
Practice Address - Street 1:4595 TOWNE LAKE PKWY STE 130
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-5514
Practice Address - Country:US
Practice Address - Phone:770-262-7943
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-23
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical