MEDICARE: MRS. EARLINE F WILLCOTT LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	04780	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0052CY	OTHER	TX	BLUE CROSS BLUE SHIELD
2	S69504	OTHER	TX	MAGELLAN

General Provider Information

NPI Number	:	1083612766
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. EARLINE F WILLCOTT LCSW

Provider Business Mailing Address
First Line	:	PO BOX 58482
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77258-8482
Country	:	US
Telephone Number	:	281-218-7346
Fax Number	:	281-286-3015

Provider Business Practice Location Address
First Line	:	1322 SPACE PARK DR
Second Line	:	SUITE C105
City	:	HOUSTON
State	:	TX
Zip	:	77058
Country	:	US
Telephone Number	:	281-218-7346
Fax Number	:	281-286-3015

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/07/2005
Last Update Date	:	12/19/2007

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