=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598419897
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEL RAE PHOENIX-WILCOX LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2022
-----------------------------------------------------
Last Update Date | 05/29/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1406 FAIR WAY
-----------------------------------------------------
City | CALISTOGA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94515-1305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-942-6888
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 365
-----------------------------------------------------
City | WINDSOR
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95492-0365
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-559-6478
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 130426
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------