Provider Demographics
NPI:1619426046
Name:WILCOX, MICHAEL WARREN (MA, MA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:WARREN
Last Name:WILCOX
Suffix:
Gender:M
Credentials:MA, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3554 ROUND BARN BLVD STE 212
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-0931
Mailing Address - Country:US
Mailing Address - Phone:707-571-3778
Mailing Address - Fax:
Practice Address - Street 1:3554 ROUND BARN BLVD STE 212
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-0931
Practice Address - Country:US
Practice Address - Phone:707-571-3778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-27
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALPCC8013101YP2500X
CAAPCC4902101YP2500X
CA4902101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty