Provider Demographics
NPI:1932980976
Name:WYNN, ASA (CPS-MH/AD, WHWC, FPM)
Entity Type:Individual
Prefix:
First Name:ASA
Middle Name:
Last Name:WYNN
Suffix:
Gender:M
Credentials:CPS-MH/AD, WHWC, FPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 SIOUX PATH
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30132-1620
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30 SIOUX PATH
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:GA
Practice Address - Zip Code:30132-1620
Practice Address - Country:US
Practice Address - Phone:770-676-2676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-05
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA171400000X, 373H00000X, 175T00000X
172A00000X, 172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No171400000XOther Service ProvidersHealth & Wellness Coach
No172A00000XOther Service ProvidersDriver
No172V00000XOther Service ProvidersCommunity Health Worker
No373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist