MEDICARE: DWANE WYNNE LPC PA

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1659110567
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DWANE WYNNE LPC PA

Provider Business Mailing Address
First Line	:	356 GROVERS KNOB
Second Line	:
City	:	BLOWING ROCK
State	:	NC
Zip	:	28605-9012
Country	:	US
Telephone Number	:	919-618-7120
Fax Number	:

Provider Business Practice Location Address
First Line	:	356 GROVERS KNOB
Second Line	:
City	:	BLOWING ROCK
State	:	NC
Zip	:	28605-9012
Country	:	US
Telephone Number	:	919-618-7120
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DONALD DWANE WYNNE
Credential	:	LCMHCS
Telephone Number	:	919-618-7120

Provider Enumeration Date	:	05/21/2024
Last Update Date	:	05/21/2024

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