MEDICARE: SANDRA JEAN WYNN-STELT MA LLP BCBA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	1-14-15612	MI
2	103TB0200X	Cognitive & Behavioral Psychologist	6301008405	MI
3	103TM1800X	Intellectual & Developmental Disabilities Psychologist	6301008405	MI

General Provider Information

NPI Number	:	1033398581
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SANDRA JEAN WYNN-STELT MA LLP BCBA

Provider Business Mailing Address
First Line	:	680 3 MILE RD NW
Second Line	:	SUITE C
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49544-8218
Country	:	US
Telephone Number	:	616-647-3460
Fax Number	:	616-647-3467

Provider Business Practice Location Address
First Line	:	680 3 MILE RD NW
Second Line	:	SUITE C
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49544-8218
Country	:	US
Telephone Number	:	616-647-3460
Fax Number	:	616-647-3467

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/01/2007
Last Update Date	:	04/17/2020

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