Provider Demographics
NPI:1255117479
Name:WILCOX, SUMMER CAMILLE (DPT)
Entity type:Individual
Prefix:
First Name:SUMMER
Middle Name:CAMILLE
Last Name:WILCOX
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 MAIN ST UNIT 1308
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-6077
Mailing Address - Country:US
Mailing Address - Phone:520-990-3853
Mailing Address - Fax:
Practice Address - Street 1:1850 S HOVER ST
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-6982
Practice Address - Country:US
Practice Address - Phone:303-926-3849
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-04
Last Update Date:2023-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0019153225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist