Provider Demographics
NPI:1457312415
Name:WILCOME, CYNTHIA DEBORAH (LLMSW)
Entity Type:Individual
Prefix:MS
First Name:CYNTHIA
Middle Name:DEBORAH
Last Name:WILCOME
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1206 PALMER CT
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060
Mailing Address - Country:US
Mailing Address - Phone:810-985-6235
Mailing Address - Fax:810-329-7303
Practice Address - Street 1:1322 N RIVER RD
Practice Address - Street 2:NORSERV GROUP LTD
Practice Address - City:ST CLAIR
Practice Address - State:MI
Practice Address - Zip Code:48060
Practice Address - Country:US
Practice Address - Phone:810-329-4798
Practice Address - Fax:810-329-7303
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010865251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI741335Medicaid
MI741335Medicaid