MEDICARE: TENASIA WYNN PSYD

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	103TC0700X	Clinical Psychologist	12987	FL

General Provider Information

NPI Number	:	1487351730
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TENASIA WYNN PSYD

Provider Business Mailing Address
First Line	:	2325 COMMERCE PK DR NE APT 4108
Second Line	:
City	:	PALM BAY
State	:	FL
Zip	:	32905-2663
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5240 BABCOCK ST NE STE 300A
Second Line	:
City	:	PALM BAY
State	:	FL
Zip	:	32905-4643
Country	:	US
Telephone Number	:	321-914-0113
Fax Number	:

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

Provider Enumeration Date	:	02/07/2023
Last Update Date	:	11/01/2025

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