Provider Demographics
NPI:1699216739
Name:WINGHART, ELLERY
Entity Type:Individual
Prefix:
First Name:ELLERY
Middle Name:
Last Name:WINGHART
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 1:300 INTERNATIONAL PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-5028
Mailing Address - Country:US
Mailing Address - Phone:407-908-7357
Mailing Address - Fax:
Practice Address - Street 1:4522 EXECUTIVE DR STE 201
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34119
Practice Address - Country:US
Practice Address - Phone:239-330-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-08
Last Update Date:2019-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician