Provider Demographics
NPI:1457943060
Name:WINGFIELD, KIZZY MAE (MED, CADC II)
Entity Type:Individual
Prefix:MS
First Name:KIZZY
Middle Name:MAE
Last Name:WINGFIELD
Suffix:
Gender:F
Credentials:MED, CADC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375 HAWTHORNE EXT
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-2515
Mailing Address - Country:US
Mailing Address - Phone:706-338-1046
Mailing Address - Fax:
Practice Address - Street 1:250 BRAY ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30601-2203
Practice Address - Country:US
Practice Address - Phone:706-389-6789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-04
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1440101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)