=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104216951
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | REBECCA COMIRE WILCOX MED, MS, CAS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/02/2015
-----------------------------------------------------
Last Update Date | 02/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 286 EVENTIDE DR
-----------------------------------------------------
City | FLEMING ISLAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32003-8186
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-624-0882
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 286 EVENTIDE DR
-----------------------------------------------------
City | FLEMING ISLAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32003-8186
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-624-0882
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | A10449
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TS0200X
-----------------------------------------------------
Taxonomy Name | School Psychologist
-----------------------------------------------------
License Number | SS1330
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 103TS0200X
-----------------------------------------------------
Taxonomy Name | School Psychologist
-----------------------------------------------------
License Number | PPS-0601178
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 103TS0200X
-----------------------------------------------------
Taxonomy Name | School Psychologist
-----------------------------------------------------
License Number | 10279824
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------