Provider Demographics
NPI:1043567597
Name:WINSRYG-WILD, CLEO (MA)
Entity Type:Individual
Prefix:
First Name:CLEO
Middle Name:
Last Name:WINSRYG-WILD
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16B FOREVER WILD WAY
Mailing Address - Street 2:
Mailing Address - City:EDGARTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02539
Mailing Address - Country:US
Mailing Address - Phone:774-563-8289
Mailing Address - Fax:
Practice Address - Street 1:111 EDGARTOWN RD
Practice Address - Street 2:
Practice Address - City:VINEYARD HAVEN
Practice Address - State:MA
Practice Address - Zip Code:02568-5601
Practice Address - Country:US
Practice Address - Phone:508-693-7900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-14
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor