=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114095692
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MS. PATRICIA S WYNN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/01/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 331 E 8TH ST
-----------------------------------------------------
City | ANNISTON
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36207-5731
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-236-3403
-----------------------------------------------------
Fax | 256-238-6263
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1518 HIGHLAND AVE
-----------------------------------------------------
City | ANNISTON
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36207-3932
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-238-6554
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------