MEDICARE: LISA MICHELLE WYNEKEN MSW, LCSW

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	LCSW77559	CA

General Provider Information

NPI Number	:	1801138763
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA MICHELLE WYNEKEN MSW, LCSW

Provider Business Mailing Address
First Line	:	2423 CAMINO DEL RIO S STE 205
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92108-3735
Country	:	US
Telephone Number	:	775-338-0773
Fax Number	:	775-201-0452

Provider Business Practice Location Address
First Line	:	2423 CAMINO DEL RIO S STE 205
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92108-3735
Country	:	US
Telephone Number	:	775-338-0773
Fax Number	:	775-201-0452

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

Provider Enumeration Date	:	03/19/2013
Last Update Date	:	10/24/2022

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