Provider Demographics
NPI:1730263591
Name:WILCOXSON, MILDRED A (PHD)
Entity type:Individual
Prefix:DR
First Name:MILDRED
Middle Name:A
Last Name:WILCOXSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3538 E PRESCOTT CIRCLE
Mailing Address - Street 2:
Mailing Address - City:CUYAHOGA FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44223-3398
Mailing Address - Country:US
Mailing Address - Phone:330-733-6022
Mailing Address - Fax:330-733-7887
Practice Address - Street 1:717 S CANTON RD
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44312
Practice Address - Country:US
Practice Address - Phone:330-733-6022
Practice Address - Fax:330-733-7887
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3687103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
R98713Medicare UPIN
OHCP17121Medicare ID - Type Unspecified
CP17121Medicare Oscar/Certification