Healthcare Provider Details

I. General information

NPI: 1336931203
Provider Name (Legal Business Name): MARK WYEN CDCA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2025
Last Update Date: 05/19/2025
Certification Date: 05/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 ELIZABETH PL
DAYTON OH
45417-3445
US

IV. Provider business mailing address

89 W NOTTINGHAM RD
DAYTON OH
45405-5210
US

V. Phone/Fax

Practice location:
  • Phone: 937-813-1737
  • Fax:
Mailing address:
  • Phone: 937-499-0509
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.191551
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: