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General NPI Number Information
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NPI Number | 1649202755
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Entity Type | Individual
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Provider Name | MARY G MATTISON-WYNN PSY D LP
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Gender | Female
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Dates
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Enumeration Date | 07/07/2006
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Last Update Date | 09/30/2024
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Provider Practice Location Address
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Address Line | 30 1ST AVE NE # 12
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City | BUFFALO
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State | MN
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Zip | 55313-1515
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Country | US
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Telephone | 612-670-8918
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Fax | 952-300-8194
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Provider Business Mailing Address
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Address Line | PO BOX 80
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City | HAMEL
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State | MN
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Zip | 55340-0080
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Country | US
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Telephone | 612-670-8918
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Fax | 952-300-8194
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 4961
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | LP4961
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License Number State | MN
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