Provider Demographics
NPI:1104068170
Name:SPELL, ANNIE WINGATE (PHD)
Entity type:Individual
Prefix:DR
First Name:ANNIE
Middle Name:WINGATE
Last Name:SPELL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 RUE FOUNTAINE
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-5744
Mailing Address - Country:US
Mailing Address - Phone:337-988-2874
Mailing Address - Fax:337-991-9165
Practice Address - Street 1:119 RUE FOUNTAINE
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-5744
Practice Address - Country:US
Practice Address - Phone:337-988-2874
Practice Address - Fax:337-991-9165
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-06
Last Update Date:2009-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1097103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent