Healthcare Provider Details

I. General information

NPI: 1619904976
Provider Name (Legal Business Name): KATHERINE S WILBORN PHD, LCSW, BCD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 03/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 ATLANTIC ST SUITE A
MELBOURNE BEACH FL
32951-2364
US

IV. Provider business mailing address

502 2ND AVE
MELBOURNE BEACH FL
32951-2512
US

V. Phone/Fax

Practice location:
  • Phone: 321-728-7011
  • Fax: 321-728-7011
Mailing address:
  • Phone: 321-728-7011
  • Fax: 321-728-7011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW 2128
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: