Provider Demographics
NPI:1477060606
Name:WILLCOTT, BENJAMIN CHRISTIAN
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:CHRISTIAN
Last Name:WILLCOTT
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 1:2612 N ROXBORO ST
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704-4350
Mailing Address - Country:US
Mailing Address - Phone:512-763-7594
Mailing Address - Fax:
Practice Address - Street 1:2612 N ROXBORO ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-4350
Practice Address - Country:US
Practice Address - Phone:512-843-7665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-09
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX77467101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional