=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275817488
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELIZABETH YVONNE WILCOX L.M.T.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/06/2011
-----------------------------------------------------
Last Update Date | 10/06/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 129 MAIN ST SUITE 608 UNITED BANK COMPLEX
-----------------------------------------------------
City | BECKLEY
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25801-4615
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-575-5296
-----------------------------------------------------
Fax | 304-774-0188
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 144 HOTCHKISS RD
-----------------------------------------------------
City | SLAB FORK
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25920-9505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-774-0076
-----------------------------------------------------
Fax | 304-774-0188
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 1999-0234
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------