Provider Demographics
NPI:1225186356
Name:WINGARD, PAUL J JR (LCSW-R)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:J
Last Name:WINGARD
Suffix:JR
Gender:M
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:514 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14901-2435
Mailing Address - Country:US
Mailing Address - Phone:607-331-1228
Mailing Address - Fax:607-737-6884
Practice Address - Street 1:147 W GRAY ST
Practice Address - Street 2:SUITE 214
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14901-3017
Practice Address - Country:US
Practice Address - Phone:607-331-1228
Practice Address - Fax:607-737-6884
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2010-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0696851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02763922Medicaid