Provider Demographics
NPI:1871007872
Name:WILCOX, PAYTON
Entity type:Individual
Prefix:
First Name:PAYTON
Middle Name:
Last Name:WILCOX
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6800 SW 105TH AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97008-5488
Mailing Address - Country:US
Mailing Address - Phone:971-200-1966
Mailing Address - Fax:
Practice Address - Street 1:6800 SW 105TH AVE STE 101
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97008
Practice Address - Country:US
Practice Address - Phone:971-200-1966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-29
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1018863103K00000X
106S00000X, 101Y00000X
OR171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1871007872Medicaid