Provider Demographics
NPI:1649202755
Name:MATTISON-WYNN, MARY G (PSY D LP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:G
Last Name:MATTISON-WYNN
Suffix:
Gender:F
Credentials:PSY D LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 80
Mailing Address - Street 2:
Mailing Address - City:HAMEL
Mailing Address - State:MN
Mailing Address - Zip Code:55340-0080
Mailing Address - Country:US
Mailing Address - Phone:612-670-8918
Mailing Address - Fax:952-300-8194
Practice Address - Street 1:30 1ST AVE NE # 12
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:MN
Practice Address - Zip Code:55313-1515
Practice Address - Country:US
Practice Address - Phone:612-670-8918
Practice Address - Fax:952-300-8194
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4961103TC0700X
103T00000X
MNLP4961103T00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDP426Medicaid