Provider Demographics
NPI:1679648067
Name:WINGFIELD, MARY BETH (LCSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:BETH
Last Name:WINGFIELD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1355-B LYNNFIELD RD
Mailing Address - Street 2:STE 245
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-5811
Mailing Address - Country:US
Mailing Address - Phone:901-485-1671
Mailing Address - Fax:901-373-3357
Practice Address - Street 1:1355-B LYNNFIELD RD
Practice Address - Street 2:STE 245
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-5811
Practice Address - Country:US
Practice Address - Phone:901-485-1671
Practice Address - Fax:901-373-3357
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0007891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3699456Medicaid
TN3095794OtherTN BLUE CROSS
TN3699456Medicaid