Basic Information
| Provider Information | |||||||||
| NPI: | 1659880755 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WINGFIELD | ||||||||
| FirstName: | SHINELLE | ||||||||
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| Credential: | LCDC II | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3862 W 18TH ST | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441093073 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1320 WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441132333 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2167810550 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2017 | ||||||||
| LastUpdateDate: | 09/21/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 0.121113 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 0.121113 | 01 | OH | OHIO CHEMICAL DEPENDENCY PROFESSIONALS BOARD | OTHER |