Provider Demographics
NPI:1467114561
Name:WINGFIELD, ANTHONY PAUL (CADTP)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:PAUL
Last Name:WINGFIELD
Suffix:
Gender:M
Credentials:CADTP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2406 E PARK ST
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95205-4636
Mailing Address - Country:US
Mailing Address - Phone:209-423-3007
Mailing Address - Fax:
Practice Address - Street 1:1111 N EL DORADO ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95202-1305
Practice Address - Country:US
Practice Address - Phone:209-938-0228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-06
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12284101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)