Provider Demographics
NPI:1912736307
Name:WYNN, ANDREW ROSS (LCSW)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:ROSS
Last Name:WYNN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4597 CLEARWATER CT
Mailing Address - Street 2:
Mailing Address - City:DUMFRIES
Mailing Address - State:VA
Mailing Address - Zip Code:22025-1422
Mailing Address - Country:US
Mailing Address - Phone:323-445-3857
Mailing Address - Fax:
Practice Address - Street 1:2680 OPITZ BLVD STE 220
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-6821
Practice Address - Country:US
Practice Address - Phone:703-828-4052
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-01
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040171521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty