Provider Demographics
NPI:1619904976
Name:WILBORN, KATHERINE S (PHD, LCSW, BCD)
Entity Type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:S
Last Name:WILBORN
Suffix:
Gender:F
Credentials:PHD, LCSW, BCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32951-2512
Mailing Address - Country:US
Mailing Address - Phone:321-728-7011
Mailing Address - Fax:321-728-7011
Practice Address - Street 1:1010 ATLANTIC ST
Practice Address - Street 2:SUITE A
Practice Address - City:MELBOURNE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32951-2364
Practice Address - Country:US
Practice Address - Phone:321-728-7011
Practice Address - Fax:321-728-7011
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-26
Last Update Date:2013-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW 21281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL230047000Medicaid
FLE0846OtherMEDICARE PART B
FLE0846OtherMEDICARE PART B