Healthcare Provider Details

I. General information

NPI: 1154748689
Provider Name (Legal Business Name): SHANELL WINGFIELD MFTI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2014
Last Update Date: 06/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2291 W MARCH LN SUITE C-101
STOCKTON CA
95207-6652
US

IV. Provider business mailing address

4441 E KINGS CANYON RD
FRESNO CA
93702-3604
US

V. Phone/Fax

Practice location:
  • Phone: 916-388-6372
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberIMF70572
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: