Provider Demographics
NPI:1558887828
Name:WINGO, SAMANTHA
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:WINGO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:691 SHOESTRING RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-8302
Mailing Address - Country:US
Mailing Address - Phone:740-301-4413
Mailing Address - Fax:740-446-2159
Practice Address - Street 1:3086 STATE ROUTE 160
Practice Address - Street 2:
Practice Address - City:GALLIPOLIS
Practice Address - State:OH
Practice Address - Zip Code:45631-8409
Practice Address - Country:US
Practice Address - Phone:740-446-5500
Practice Address - Fax:740-446-2159
Is Sole Proprietor?:No
Enumeration Date:2017-08-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.163715101YA0400X
OHS21061101041S0200X
OHLCDCIII.162216101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool