Provider Demographics
NPI:1164531091
Name:WINGARD, GERALD L (PHD)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:L
Last Name:WINGARD
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23350 COUNTY ROAD 38
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-9384
Mailing Address - Country:US
Mailing Address - Phone:574-862-3100
Mailing Address - Fax:574-862-4900
Practice Address - Street 1:23350 COUNTY ROAD 38
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-9384
Practice Address - Country:US
Practice Address - Phone:574-862-3100
Practice Address - Fax:574-862-4900
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040098103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000176605OtherANTHEM BLUECROSS & BLUE S