Provider Demographics
NPI:1992917637
Name:WYNIA, ELLY MAY (MSW, LCSW)
Entity type:Individual
Prefix:MS
First Name:ELLY
Middle Name:MAY
Last Name:WYNIA
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53700 GENERATIONS DRIVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46635
Mailing Address - Country:US
Mailing Address - Phone:574-258-6300
Mailing Address - Fax:574-258-6310
Practice Address - Street 1:53700 GENERATIONS DRIVE
Practice Address - Street 2:SUITE 200
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635
Practice Address - Country:US
Practice Address - Phone:574-258-6300
Practice Address - Fax:574-258-6310
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34003365A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical