Active NPI
Matthew John Wynn, PHD
- Clinical Psychologist
- Piedmont, CA
National Provider Identifier
1013777036
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Psychologist
- License
- 34922
- Practice address
- 539 Blair Ave
Piedmont, CA 94611-3734 - Phone
- (510) 519-1928
- NPI assigned
- Mar 19, 2024
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Psychologist | 103TC0700X | 34922 | CA | Primary |
Addresses
Primary practice location
539 Blair Ave
Piedmont, CA 94611-3734
Mailing address
PO Box 11396
Oakland, CA 94611-0396
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Opted out of Medicare
- Yes, effective Mar 19, 2024 through Mar 19, 2028
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Doctor of Philosophy
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1710806400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1710806400000",
"number": "1013777036",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "PO BOX 11396",
"city": "OAKLAND",
"state": "CA",
"postal_code": "946110396"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "539 BLAIR AVE",
"city": "PIEDMONT",
"state": "CA",
"postal_code": "946113734",
"telephone_number": "510-519-1928"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WYNN",
"first_name": "MATTHEW",
"middle_name": "JOHN",
"credential": "PHD",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2024-03-19",
"last_updated": "2024-03-19",
"certification_date": "2024-03-19",
"status": "A"
},
"taxonomies": [
{
"code": "103TC0700X",
"taxonomy_group": "",
"desc": "Psychologist, Clinical",
"state": "CA",
"license": "34922",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Piedmont, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 19, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Opt Out Affidavits.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.