Provider Demographics
NPI:1225596760
Name:WILCOX, MADISON BLAIR
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:BLAIR
Last Name:WILCOX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1342 TOBACCO RD
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:NC
Mailing Address - Zip Code:28340-5532
Mailing Address - Country:US
Mailing Address - Phone:910-740-4043
Mailing Address - Fax:
Practice Address - Street 1:5948 FISHER RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-5640
Practice Address - Country:US
Practice Address - Phone:910-242-4114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-04
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12361225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist