Provider Demographics
NPI:1174602601
Name:WINGATE, BERYL LESLIE (PSYD)
Entity type:Individual
Prefix:DR
First Name:BERYL
Middle Name:LESLIE
Last Name:WINGATE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1219 MARQUETTE AVE.
Mailing Address - Street 2:SUITE # 80
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55403-2489
Mailing Address - Country:US
Mailing Address - Phone:612-338-9012
Mailing Address - Fax:612-338-9020
Practice Address - Street 1:1219 MARQUETTE AVE
Practice Address - Street 2:SUITE # 80
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55403-2488
Practice Address - Country:US
Practice Address - Phone:612-338-9012
Practice Address - Fax:612-338-9020
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4332103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN426S4WIOtherBCBS
MNHP36316OtherHEALTHPARTNERS