Healthcare Provider Details

I. General information

NPI: 1790127330
Provider Name (Legal Business Name): MICHELLE WYNNE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2013
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 SILVER ST UNIT 216
AGAWAM MA
01001-3067
US

IV. Provider business mailing address

68 MANCHESTER TER
SPRINGFIELD MA
01108-3455
US

V. Phone/Fax

Practice location:
  • Phone: 413-636-6010
  • Fax:
Mailing address:
  • Phone: 413-896-6411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLICSW1141456
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: