Provider Demographics
NPI:1669763736
Name:WILCOX, TARA REGINA
Entity type:Individual
Prefix:MS
First Name:TARA
Middle Name:REGINA
Last Name:WILCOX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:955 53RD ST E
Mailing Address - Street 2:APT. 123
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34208-5890
Mailing Address - Country:US
Mailing Address - Phone:941-467-2315
Mailing Address - Fax:
Practice Address - Street 1:1748 INDEPENDENCE BLVD STE D1
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34234-2151
Practice Address - Country:US
Practice Address - Phone:941-359-1927
Practice Address - Fax:941-359-1929
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-25
Last Update Date:2011-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health