Provider Demographics
NPI:1104140771
Name:WILCOX, KRISTEN (LCSW)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:WILCOX
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 BROAD ST
Mailing Address - Street 2:FAMILY ADVOCACY
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-3204
Mailing Address - Country:US
Mailing Address - Phone:860-358-3401
Mailing Address - Fax:860-358-3403
Practice Address - Street 1:51 BROAD ST
Practice Address - Street 2:FAMILY ADVOCACY
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-3204
Practice Address - Country:US
Practice Address - Phone:860-358-3401
Practice Address - Fax:860-358-3403
Is Sole Proprietor?:No
Enumeration Date:2010-03-25
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT72531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT7253OtherCT LCSW LICENSE #