Healthcare Provider Details

I. General information

NPI: 1689505307
Provider Name (Legal Business Name): LADARIUS MARKEL WILCOX
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2026
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13700 58TH ST N STE 209
CLEARWATER FL
33760-3757
US

IV. Provider business mailing address

13700 58TH ST N UNIT 209
CLEARWATER FL
33760-3757
US

V. Phone/Fax

Practice location:
  • Phone: 727-223-6454
  • Fax:
Mailing address:
  • Phone: 727-223-6454
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberW238267138000
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: