Basic Information
| Provider Information | |||||||||
| NPI: | 1952546137 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WYNN | ||||||||
| FirstName: | KASSANDRA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | INTERN, | ||||||||
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| Mailing Information | |||||||||
| Address1: | 722 W AVENUE J9 | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935344941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6613416142 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 44447 10TH ST W | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935343324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6617262630 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2008 | ||||||||
| LastUpdateDate: | 12/02/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.