Provider Demographics
NPI:1770714156
Name:WILCOX, ELIZABETH ANNE
Entity type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:ANNE
Last Name:WILCOX
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:BETH
Other - Middle Name:
Other - Last Name:WILCOX
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:211 BARBOUR ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:KY
Mailing Address - Zip Code:42450-1707
Mailing Address - Country:US
Mailing Address - Phone:270-213-0363
Mailing Address - Fax:270-639-0012
Practice Address - Street 1:211 BARBOUR ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:KY
Practice Address - Zip Code:42450-1707
Practice Address - Country:US
Practice Address - Phone:270-213-0363
Practice Address - Fax:270-639-0012
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-03
Last Update Date:2009-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY200202485222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist