Provider Demographics
NPI:1124485602
Name:WYNN, CARLOS MIKKEL (OTR/L)
Entity type:Individual
Prefix:MR
First Name:CARLOS
Middle Name:MIKKEL
Last Name:WYNN
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 CORNELL CT
Mailing Address - Street 2:
Mailing Address - City:STATHAM
Mailing Address - State:GA
Mailing Address - Zip Code:30666-2046
Mailing Address - Country:US
Mailing Address - Phone:706-817-1663
Mailing Address - Fax:
Practice Address - Street 1:545 OLD NORCROSS RD
Practice Address - Street 2:SUITE 100
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-3389
Practice Address - Country:US
Practice Address - Phone:678-377-2833
Practice Address - Fax:678-377-2882
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-28
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT006330225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist