Individual
ASA WYNN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CPS-MH/AD, WHWC, FPM
Contact information
Practice address
30 SIOUX PATH, DALLAS, GA 30132-1620
(770) 676-2676
Mailing address
30 SIOUX PATH, DALLAS, GA 30132-1620
Taxonomy
Speciality
Code
Description
License number
State
171400000X
Health & Wellness Coach
—
GA
172A00000X
Driver
—
—
172V00000X
Community Health Worker
—
—
175T00000X
Peer Specialist
Primary
—
GA
373H00000X
Day Training/Habilitation Specialist
—
GA
Other
Enumeration date
10/05/2023
Last updated
10/05/2023
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