=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437582467
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SANDRA GAIL WILCOX LPC, MA, MDIV
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/13/2013
-----------------------------------------------------
Last Update Date | 08/13/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4131 SPICEWOOD SPRINGS RD SUITE C4
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78759-8661
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-585-6457
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5505 MAPLELEAF DR
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78723-2610
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-585-6457
-----------------------------------------------------
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 | 66947
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------