Healthcare Provider Details

I. General information

NPI: 1649727520
Provider Name (Legal Business Name): KRISTEN WILCOX LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2016
Last Update Date: 01/20/2022
Certification Date: 01/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

257 MAIN ST
BINGHAMTON NY
13905-2522
US

IV. Provider business mailing address

1200 E MAIN ST
ENDICOTT NY
13760-5220
US

V. Phone/Fax

Practice location:
  • Phone: 607-729-6206
  • Fax: 607-729-1858
Mailing address:
  • Phone: 607-757-2143
  • Fax: 607-658-7119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number092126
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: