Provider Demographics
NPI:1437312246
Name:GEORGIA WILCOX AND ASSOCIATES PC
Entity type:Organization
Organization Name:GEORGIA WILCOX AND ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGIA
Authorized Official - Middle Name:GAYLE
Authorized Official - Last Name:WILCOX
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:503-452-2797
Mailing Address - Street 1:2800 N VANCOUVER AVE
Mailing Address - Street 2:#231
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1643
Mailing Address - Country:US
Mailing Address - Phone:503-452-2797
Mailing Address - Fax:
Practice Address - Street 1:2800 N VANCOUVER AVE
Practice Address - Street 2:#231
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1643
Practice Address - Country:US
Practice Address - Phone:503-452-2797
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-02
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1455261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR111880Medicare UPIN