Provider Demographics
NPI:1295808335
Name:WILCOX, CYNTHIA ELAINE (PHD)
Entity type:Individual
Prefix:DR
First Name:CYNTHIA
Middle Name:ELAINE
Last Name:WILCOX
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:CYNTHIA
Other - Middle Name:ELAINE
Other - Last Name:FORMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:4545 EVERHARD RD NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-2406
Mailing Address - Country:US
Mailing Address - Phone:330-494-3727
Mailing Address - Fax:330-494-3764
Practice Address - Street 1:4545 EVERHARD RD NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-2406
Practice Address - Country:US
Practice Address - Phone:330-494-3727
Practice Address - Fax:330-494-3764
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4715103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0930961Medicaid
WICP13291Medicare ID - Type Unspecified