Provider Demographics
NPI:1831564830
Name:WYNNE, THOMAS FRANK (CDP)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:FRANK
Last Name:WYNNE
Suffix:
Gender:M
Credentials:CDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1712 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-2701
Mailing Address - Country:US
Mailing Address - Phone:509-731-1616
Mailing Address - Fax:
Practice Address - Street 1:515 LAKEWAY DR
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-5233
Practice Address - Country:US
Practice Address - Phone:360-676-2187
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-02
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP 60229257101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)