Provider Demographics
NPI:1881096410
Name:WILLCOT, DONNELL EUGENE JR (MSW, ASW)
Entity type:Individual
Prefix:
First Name:DONNELL
Middle Name:EUGENE
Last Name:WILLCOT
Suffix:JR
Gender:M
Credentials:MSW, ASW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13616 CERISE AVE
Mailing Address - Street 2:APT. 5
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-7791
Mailing Address - Country:US
Mailing Address - Phone:310-691-9174
Mailing Address - Fax:
Practice Address - Street 1:1801 LAKE SHORE AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90026-1715
Practice Address - Country:US
Practice Address - Phone:323-580-0643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-26
Last Update Date:2014-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA614661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical