Provider Demographics
NPI:1801834684
Name:WILKERSON, REBECCA L (LCSW)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:L
Last Name:WILKERSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:
Other - Last Name:LEVEQUE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7431 114TH AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33773-5119
Mailing Address - Country:US
Mailing Address - Phone:800-632-6074
Mailing Address - Fax:
Practice Address - Street 1:120 PENMARC DR
Practice Address - Street 2:SUITE 118
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27603-2400
Practice Address - Country:US
Practice Address - Phone:800-632-6074
Practice Address - Fax:866-341-7509
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC004406101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6007015Medicaid
NC2875235Medicare ID - Type UnspecifiedPROVIDER # WITH PARADIGM
NC2875235Medicare PIN