Provider Demographics
NPI:1952708570
Name:WYNN, WILLARD II
Entity Type:Individual
Prefix:
First Name:WILLARD
Middle Name:
Last Name:WYNN
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1450 SPRUCE STREET SUITE A
Mailing Address - Street 2:
Mailing Address - City:WHITTIER
Mailing Address - State:CA
Mailing Address - Zip Code:92597-2410
Mailing Address - Country:US
Mailing Address - Phone:951-715-5040
Mailing Address - Fax:
Practice Address - Street 1:1405 SPRUCE STREET SUITE A
Practice Address - Street 2:
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:92597-2410
Practice Address - Country:US
Practice Address - Phone:951-715-5040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-25
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator