Provider Demographics
NPI:1629302088
Name:WILCOX, ROSE
Entity Type:Individual
Prefix:MS
First Name:ROSE
Middle Name:
Last Name:WILCOX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:365 FULTON ST
Mailing Address - Street 2:SUPPORT SERVICES
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94102-4423
Mailing Address - Country:US
Mailing Address - Phone:415-857-6611
Mailing Address - Fax:
Practice Address - Street 1:365 FULTON ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94102-4423
Practice Address - Country:US
Practice Address - Phone:415-857-6611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-01
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA305881041C0700X
CALCSW64022101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical