Provider Demographics
NPI:1396451241
Name:DE ELLA D WILCOX LLC
Entity type:Organization
Organization Name:DE ELLA D WILCOX LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DE ELLA
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:WILCOX
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:218-639-2805
Mailing Address - Street 1:PO BOX 7430
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56302-7430
Mailing Address - Country:US
Mailing Address - Phone:320-460-2550
Mailing Address - Fax:320-217-5453
Practice Address - Street 1:2233 ROOSEVELT RD. STE. 1
Practice Address - Street 2:2233 ROOSEVELT RD. STE. 1
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301
Practice Address - Country:US
Practice Address - Phone:320-460-2550
Practice Address - Fax:320-217-5453
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-24
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)