Provider Demographics
NPI:1568453645
Name:WILMOTH, JANICE R (PHD,PSYD,LCAS,CCS)
Entity Type:Individual
Prefix:DR
First Name:JANICE
Middle Name:R
Last Name:WILMOTH
Suffix:
Gender:F
Credentials:PHD,PSYD,LCAS,CCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 LILLY LN
Mailing Address - Street 2:
Mailing Address - City:LOWGAP
Mailing Address - State:NC
Mailing Address - Zip Code:27024-9186
Mailing Address - Country:US
Mailing Address - Phone:336-401-6242
Mailing Address - Fax:336-352-4483
Practice Address - Street 1:124 W KAPP ST
Practice Address - Street 2:
Practice Address - City:DOBSON
Practice Address - State:NC
Practice Address - Zip Code:27017-8825
Practice Address - Country:US
Practice Address - Phone:336-401-6242
Practice Address - Fax:336-352-4483
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-29
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3142103G00000X, 103TA0400X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)