Provider Demographics
NPI:1801830476
Name:WINGETT, KRYSTAL R E (LMSW, ASCW)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:R E
Last Name:WINGETT
Suffix:
Gender:F
Credentials:LMSW, ASCW
Other - Prefix:
Other - First Name:KRYSTAL
Other - Middle Name:
Other - Last Name:EDWARDS; JOHNSTON; GOLEC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:28000 DEQUINDRE RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48092-2468
Mailing Address - Country:US
Mailing Address - Phone:586-753-0405
Mailing Address - Fax:586-753-0404
Practice Address - Street 1:3950 S ROCHESTER RD
Practice Address - Street 2:#1400
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48307-5160
Practice Address - Country:US
Practice Address - Phone:248-844-6234
Practice Address - Fax:248-844-6237
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801060114104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIQ26426237Medicare ID - Type Unspecified