Provider Demographics
NPI:1902082894
Name:WING, ROBERT L
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:L
Last Name:WING
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94 N ELM ST STE 205
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01085-1641
Mailing Address - Country:US
Mailing Address - Phone:413-568-0850
Mailing Address - Fax:413-562-1476
Practice Address - Street 1:94 N ELM ST STE 205
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:MA
Practice Address - Zip Code:01085-1641
Practice Address - Country:US
Practice Address - Phone:413-568-0850
Practice Address - Fax:413-562-1476
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-10
Last Update Date:2008-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3254103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0513954Medicaid
MAW03345OtherMEDICARE
MAW03345OtherBLUE CROSS BLUE SHIELD
17783OtherHEALTH NEW ENGLAND
R45013Medicare UPIN