Provider Demographics
NPI:1528603032
Name:WINGO, JOEL RUSSELL
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:RUSSELL
Last Name:WINGO
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:GRAND LAKE MENTAL HEALTH CENTER, INC
Mailing Address - Street 2:604 SOUTH WALNUT
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74074-4222
Mailing Address - Country:US
Mailing Address - Phone:918-857-6280
Mailing Address - Fax:
Practice Address - Street 1:GRAND LAKE MENTAL HEALTH CENTER INC.
Practice Address - Street 2:604 S. WALNUT ST.
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-4222
Practice Address - Country:US
Practice Address - Phone:918-857-6280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-08
Last Update Date:2019-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator