Healthcare Provider Details

I. General information

NPI: 1427704634
Provider Name (Legal Business Name): DANIEL PAUL WILCOX GRAD STUDENT TRAINEE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2022
Last Update Date: 02/25/2022
Certification Date: 01/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

960 E GREEN ST STE 280
PASADENA CA
91106-2419
US

IV. Provider business mailing address

2011 FAIR PARK AVE
LOS ANGELES CA
90041-1918
US

V. Phone/Fax

Practice location:
  • Phone: 714-824-7441
  • Fax:
Mailing address:
  • Phone: 714-824-7441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: