Healthcare Provider Details

I. General information

NPI: 1407589716
Provider Name (Legal Business Name): ANDREW WYNKOOP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2022
Last Update Date: 01/04/2026
Certification Date: 01/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2850 COURTNEY CREEK BLVD APT 233
DURHAM NC
27713-1664
US

IV. Provider business mailing address

2850 COURTNEY CREEK BLVD APT 233
DURHAM NC
27713-1664
US

V. Phone/Fax

Practice location:
  • Phone: 919-797-3379
  • Fax:
Mailing address:
  • Phone: 919-797-3379
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC019444
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: