Provider Demographics
NPI:1720166283
Name:WINGFIELD, CECIL W (PHD)
Entity Type:Individual
Prefix:DR
First Name:CECIL
Middle Name:W
Last Name:WINGFIELD
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11710 PARLIAMENT ST APT 901
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78213-1167
Mailing Address - Country:US
Mailing Address - Phone:210-265-1931
Mailing Address - Fax:
Practice Address - Street 1:616 W RUSSELL PL
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-3658
Practice Address - Country:US
Practice Address - Phone:800-257-8715
Practice Address - Fax:800-819-1655
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21785103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX86041AOtherBLUE CROSS BLUE SHIELD
TX82231PMedicare ID - Type Unspecified