Provider Demographics
NPI:1356742787
Name:WYNDHAM, SANDRA WYNN
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:WYNN
Last Name:WYNDHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2105 CRUMS LN
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40216-4231
Mailing Address - Country:US
Mailing Address - Phone:502-589-8950
Mailing Address - Fax:502-449-3690
Practice Address - Street 1:2105 CRUMS LN
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40216-4231
Practice Address - Country:US
Practice Address - Phone:502-589-8950
Practice Address - Fax:502-449-3690
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-04
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY 19671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical