Provider Information for 1164859989
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Mr. DAVID WYNN LCSW
Sex: Male
NPI: 1164859989
Last Updated: 2016-03-16
Certification Date:
Certification Date:
Details
| Name | Value | ||||||||
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| NPI | 1164859989 | ||||||||
| Enumeration Date | 2013-10-11 | ||||||||
| NPI Type | NPI-1 Individual | ||||||||
| Sole Proprietor | NO | ||||||||
| Status | Active | ||||||||
| Mailing Address | 3340 E GOLDSTONE WAY MERIDIAN, ID 83642-1026 United States Phone: 208-367-2175 | Fax:208-376-0285 | ||||||||
| Primary Practice Address | 131 N ALLUMBAUGH ST BOISE, ID 83704-9204 United States Phone: 208-367-2175 | Fax:208-376-0285 | ||||||||
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