Provider Demographics
NPI:1528295300
Name:WINGFIELD, MIRIAM H (MA)
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:H
Last Name:WINGFIELD
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:MERRY
Other - Middle Name:
Other - Last Name:WINGFIELD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA LMFT
Mailing Address - Street 1:3527 MT DIABLO BLVD
Mailing Address - Street 2:#376
Mailing Address - City:LAFAYETTE
Mailing Address - State:CA
Mailing Address - Zip Code:94549-3815
Mailing Address - Country:US
Mailing Address - Phone:925-407-6845
Mailing Address - Fax:
Practice Address - Street 1:3468 MT DIABLO BLVD
Practice Address - Street 2:B-201
Practice Address - City:LAFAYETTE
Practice Address - State:CA
Practice Address - Zip Code:94549-3957
Practice Address - Country:US
Practice Address - Phone:925-407-6845
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-18
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC51380106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist