MEDICARE: MARY G MATTISON-WYNN PSY D LP

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	4961	MN
2	103T00000X	Psychologist
3	103T00000X	Psychologist	LP4961	MN

General Provider Information

NPI Number	:	1649202755
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY G MATTISON-WYNN PSY D LP

Provider Business Mailing Address
First Line	:	PO BOX 80
Second Line	:
City	:	HAMEL
State	:	MN
Zip	:	55340-0080
Country	:	US
Telephone Number	:	612-670-8918
Fax Number	:	952-300-8194

Provider Business Practice Location Address
First Line	:	30 1ST AVE NE # 12
Second Line	:
City	:	BUFFALO
State	:	MN
Zip	:	55313-1515
Country	:	US
Telephone Number	:	612-670-8918
Fax Number	:	952-300-8194

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

Provider Enumeration Date	:	07/07/2006
Last Update Date	:	09/30/2024

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