Provider Demographics
NPI:1447498589
Name:WILCOX, KIMBERLY
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
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 1:2215 RIO DE JANEIRO AVE
Mailing Address - Street 2:
Mailing Address - City:PUNTA GORDA
Mailing Address - State:FL
Mailing Address - Zip Code:33983-8674
Mailing Address - Country:US
Mailing Address - Phone:941-467-6347
Mailing Address - Fax:
Practice Address - Street 1:25166 MARION AVE
Practice Address - Street 2:STE 112
Practice Address - City:PUNTA GORDA
Practice Address - State:FL
Practice Address - Zip Code:33950-4017
Practice Address - Country:US
Practice Address - Phone:941-467-6347
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-28
Last Update Date:2010-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4729CAP103TA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)