MEDICARE: EGAN WYNNE

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	106S00000X	Behavior Technician
2	106E00000X	Assistant Behavior Analyst	0-26-170033	NM

General Provider Information

NPI Number	:	1871244996
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EGAN WYNNE

Provider Business Mailing Address
First Line	:	2805 S INDUSTRIAL HWY STE 100
Second Line	:
City	:	ANN ARBOR
State	:	MI
Zip	:	48104-6791
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	10131 COORS BLVD NW STE I1
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87114-4048
Country	:	US
Telephone Number	:	505-336-0560
Fax Number	:

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

Provider Enumeration Date	:	01/11/2022
Last Update Date	:	06/15/2026

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Directions to “ EGAN WYNNE ” Practice Location

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