Provider Demographics
NPI:1578339800
Name:WILCOX, JUSTINA SHANE (LMHC-A)
Entity Type:Individual
Prefix:
First Name:JUSTINA
Middle Name:SHANE
Last Name:WILCOX
Suffix:
Gender:F
Credentials:LMHC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19414 AURORA AVE N UNIT 202
Mailing Address - Street 2:
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98133-3936
Mailing Address - Country:US
Mailing Address - Phone:425-501-6471
Mailing Address - Fax:
Practice Address - Street 1:19414 AURORA AVE N UNIT 202
Practice Address - Street 2:
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98133-3936
Practice Address - Country:US
Practice Address - Phone:425-501-6471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-28
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC60122680101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health