Provider Demographics
NPI:1669828687
Name:WILCOX, DEBRA (LMT)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:
Last Name:WILCOX
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 MECHEM DR STE 5
Mailing Address - Street 2:
Mailing Address - City:RUIDOSO
Mailing Address - State:NM
Mailing Address - Zip Code:88345-7060
Mailing Address - Country:US
Mailing Address - Phone:575-802-3791
Mailing Address - Fax:
Practice Address - Street 1:1009 MECHEM DR STE 5
Practice Address - Street 2:
Practice Address - City:RUIDOSO
Practice Address - State:NM
Practice Address - Zip Code:88345-7060
Practice Address - Country:US
Practice Address - Phone:575-802-3791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-09
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM8242173C00000X, 174400000X
225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No173C00000XOther Service ProvidersReflexologist
No174400000XOther Service ProvidersSpecialist