Healthcare Provider Details

I. General information

NPI: 1881502342
Provider Name (Legal Business Name): MARIAH NICHELLE WYNN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2026
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12669 ENCINITAS AVE
SYLMAR CA
91342-3635
US

IV. Provider business mailing address

2225 E CESAR E CHAVEZ AVE # 1001
LOS ANGELES CA
90033-1845
US

V. Phone/Fax

Practice location:
  • Phone: 800-700-8705
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number164963
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: