Provider Demographics
NPI:1043267412
Name:WYNNE, DONALD DWANE (LCMHCS)
Entity type:Individual
Prefix:MR
First Name:DONALD
Middle Name:DWANE
Last Name:WYNNE
Suffix:
Gender:M
Credentials:LCMHCS
Other - Prefix:
Other - First Name:DONALD
Other - Middle Name:D
Other - Last Name:WYNNE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCMHCS
Mailing Address - Street 1:356 GROVERS KNOB
Mailing Address - Street 2:
Mailing Address - City:BLOWING ROCK
Mailing Address - State:NC
Mailing Address - Zip Code:28605-9012
Mailing Address - Country:US
Mailing Address - Phone:919-618-7120
Mailing Address - Fax:
Practice Address - Street 1:356 GROVERS KNOB
Practice Address - Street 2:
Practice Address - City:BLOWING ROCK
Practice Address - State:NC
Practice Address - Zip Code:28605-9012
Practice Address - Country:US
Practice Address - Phone:919-618-7120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-30
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCS3106101YM0800X
NC3106101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health