Provider Demographics
NPI:1699898874
Name:WILCOX, CHARLES TIMOTHY (LPC, LMFT)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:TIMOTHY
Last Name:WILCOX
Suffix:
Gender:M
Credentials:LPC, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 178
Mailing Address - Street 2:
Mailing Address - City:ELYSIAN FIELDS
Mailing Address - State:TX
Mailing Address - Zip Code:75642-0178
Mailing Address - Country:US
Mailing Address - Phone:318-221-9300
Mailing Address - Fax:318-212-5206
Practice Address - Street 1:2520 LINE AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-3022
Practice Address - Country:US
Practice Address - Phone:318-221-9300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1571101YM0800X
LA89106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist