Provider Demographics
NPI:1508581257
Name:WINGFIELD, ELLIOT GEORGE
Entity Type:Individual
Prefix:
First Name:ELLIOT
Middle Name:GEORGE
Last Name:WINGFIELD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 CONCORD AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520-4969
Mailing Address - Country:US
Mailing Address - Phone:187-791-0653
Mailing Address - Fax:
Practice Address - Street 1:10390 COLOMA RD
Practice Address - Street 2:
Practice Address - City:RANCHO CORDOVA
Practice Address - State:CA
Practice Address - Zip Code:95670-2152
Practice Address - Country:US
Practice Address - Phone:187-791-0653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-05
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X, 106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health