Healthcare Provider Details

I. General information

NPI: 1225404437
Provider Name (Legal Business Name): TIFFANY WYNN PHD, LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2015
Last Update Date: 07/29/2024
Certification Date: 07/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2727 SAN PEDRO DR NE STE 110
ALBUQUERQUE NM
87110-3373
US

IV. Provider business mailing address

300 MENAUL BLVD NW # 2360
ALBUQUERQUE NM
87107-1322
US

V. Phone/Fax

Practice location:
  • Phone: 505-670-7765
  • Fax:
Mailing address:
  • Phone: 505-670-7765
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCCMH0203641
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCCMH0203641
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: