=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821816190
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL WYNNE RBT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2024
-----------------------------------------------------
Last Update Date | 03/27/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4840 GRASSELLI ST
-----------------------------------------------------
City | EAST CHICAGO
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46312-3503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-341-7706
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4844 PINE AVE
-----------------------------------------------------
City | HAMMOND
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46327-1843
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-341-7706
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number | RBT-20-145195
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------