MEDICARE: KATHERINE AVIVA WYNN LSWAIC

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	1041C0700X	Clinical Social Worker	SC61553232	WA
2	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1598549073
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHERINE AVIVA WYNN LSWAIC

Provider Business Mailing Address
First Line	:	8015 SE 28TH STREET
Second Line	:
City	:	MERCER ISLAND
State	:	WA
Zip	:	98040
Country	:	US
Telephone Number	:	206-276-1549
Fax Number	:

Provider Business Practice Location Address
First Line	:	8015 SE 28TH STREET
Second Line	:
City	:	MERCER ISLAND
State	:	WA
Zip	:	98040
Country	:	US
Telephone Number	:	206-236-1294
Fax Number	:

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

Provider Enumeration Date	:	08/24/2023
Last Update Date	:	12/04/2025

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