Provider Demographics
NPI:1154837235
Name:WILCOCK, MARION DIANE
Entity type:Individual
Prefix:
First Name:MARION
Middle Name:DIANE
Last Name:WILCOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5225 NORTON RD
Mailing Address - Street 2:
Mailing Address - City:GROVE CITY
Mailing Address - State:OH
Mailing Address - Zip Code:43123-9664
Mailing Address - Country:US
Mailing Address - Phone:614-668-3277
Mailing Address - Fax:419-747-4126
Practice Address - Street 1:3042 MCKINLEY AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43204-3653
Practice Address - Country:US
Practice Address - Phone:614-487-7805
Practice Address - Fax:419-747-4126
Is Sole Proprietor?:No
Enumeration Date:2017-12-27
Last Update Date:2017-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORBT-17-36147106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician