Healthcare Provider Details

I. General information

NPI: 1780214502
Provider Name (Legal Business Name): MR. GODWIN DEWAYNE WYCHE II
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/21/2020
Last Update Date: 01/21/2020
Certification Date: 01/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14644 KRISTENRIGHT LN
ORLANDO FL
32826-5305
US

IV. Provider business mailing address

2700 WESTHALL LN
MAITLAND FL
32751-7203
US

V. Phone/Fax

Practice location:
  • Phone: 979-479-1538
  • Fax:
Mailing address:
  • Phone: 800-840-2528
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: