Provider Demographics
NPI:1417564246
Name:WILCOX, STEVEN KYLE (NMT)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:KYLE
Last Name:WILCOX
Suffix:
Gender:M
Credentials:NMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4470 W SUNSET BLVD # 92947
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-6302
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4470 W SUNSET BLVD # 92947
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6302
Practice Address - Country:US
Practice Address - Phone:714-905-9801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-25
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA73854225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist