Provider Demographics
NPI:1871077826
Name:WINGATE DE ACADEMY
Entity type:Organization
Organization Name:WINGATE DE ACADEMY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NON LICENSE COUNSELOR
Authorized Official - Prefix:DR
Authorized Official - First Name:QETSIYAH
Authorized Official - Middle Name:S
Authorized Official - Last Name:YISRAE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:813-693-9449
Mailing Address - Street 1:2780 E FOWLER AVE # 174
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-6297
Mailing Address - Country:US
Mailing Address - Phone:813-359-9569
Mailing Address - Fax:813-671-8825
Practice Address - Street 1:2780 E FOWLER AVE # 174
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-6297
Practice Address - Country:US
Practice Address - Phone:813-359-9569
Practice Address - Fax:813-671-8825
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-17
Last Update Date:2018-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty