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General NPI Number Information
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NPI Number | 1750851036
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Entity Type | Individual
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Provider Name | BETHANY R WILCOX LCSW
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Gender | Female
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Dates
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Enumeration Date | 11/29/2018
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Last Update Date | 11/29/2018
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Provider Practice Location Address
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Address Line | 6037 W US HIGHWAY 90
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City | LAKE CITY
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State | FL
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Zip | 32055-8196
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Country | US
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Telephone | 386-752-9191
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Fax |
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Provider Business Mailing Address
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Address Line | 2264 NW 15TH AVE
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City | GAINESVILLE
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State | FL
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Zip | 32605-5219
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Country | US
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Telephone | 352-262-6488
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | SW15771
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License Number State | FL
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