Healthcare Provider Details

I. General information

NPI: 1275803975
Provider Name (Legal Business Name): MS. TAMARA W. WYNN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2012
Last Update Date: 01/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14650 DETROIT AVENUE SUITE LL40
LAKEWOOD OH
44107
US

IV. Provider business mailing address

14650 DETROIT AVENUE SUITE LL40
LAKEWOOD OH
44107
US

V. Phone/Fax

Practice location:
  • Phone: 216-226-2721
  • Fax: 216-226-2731
Mailing address:
  • Phone: 216-226-2721
  • Fax: 216-226-2731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number071041
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI0002521
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: