Healthcare Provider Details

I. General information

NPI: 1619312303
Provider Name (Legal Business Name): JOSHUA WYNER LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2013
Last Update Date: 05/27/2020
Certification Date: 05/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12843 LANDALE ST 3RD FLOOR
STUDIO CITY CA
91604-1352
US

IV. Provider business mailing address

12843 LANDALE ST 3RD FLOOR
STUDIO CITY CA
91604-1352
US

V. Phone/Fax

Practice location:
  • Phone: 818-533-2319
  • Fax:
Mailing address:
  • Phone: 818-533-2319
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC1805
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC53281
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: