Provider Demographics
NPI:1174540009
Name:WINGFIELD, CHARLES HARRY (LCSW CACIII)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:HARRY
Last Name:WINGFIELD
Suffix:
Gender:M
Credentials:LCSW CACIII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 E SPAULDING AVE
Mailing Address - Street 2:STE 4
Mailing Address - City:PUEBLO WEST
Mailing Address - State:CO
Mailing Address - Zip Code:81007-1668
Mailing Address - Country:US
Mailing Address - Phone:719-251-0398
Mailing Address - Fax:719-547-4056
Practice Address - Street 1:44 E SPAULDING AVE
Practice Address - Street 2:STE 4
Practice Address - City:PUEBLO WEST
Practice Address - State:CO
Practice Address - Zip Code:81007-1668
Practice Address - Country:US
Practice Address - Phone:719-564-9039
Practice Address - Fax:719-561-8752
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2049101YA0400X
CO991320104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO038715Medicaid
CO038715Medicaid