Healthcare Provider Details

I. General information

NPI: 1710970413
Provider Name (Legal Business Name): GEORGIA GAYLE WILCOX PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/26/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 N VANCOUVER AVE #231
PORTLAND OR
97227-1630
US

IV. Provider business mailing address

2800 N VANCOUVER AVE #231
PORTLAND OR
97227-1630
US

V. Phone/Fax

Practice location:
  • Phone: 503-452-2797
  • Fax: 503-413-4898
Mailing address:
  • Phone: 503-452-2797
  • Fax: 503-413-4898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1455
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: