Provider Demographics
NPI:1851604029
Name:WILCOX, KATRINA M (LCDP)
Entity type:Individual
Prefix:
First Name:KATRINA
Middle Name:M
Last Name:WILCOX
Suffix:
Gender:F
Credentials:LCDP
Other - Prefix:
Other - First Name:KATRINA
Other - Middle Name:M
Other - Last Name:COOPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:900 WARREN AVE STE 401
Mailing Address - Street 2:
Mailing Address - City:EAST PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02914-1430
Mailing Address - Country:US
Mailing Address - Phone:401-421-4000
Mailing Address - Fax:
Practice Address - Street 1:900 WARREN AVE STE 401
Practice Address - Street 2:
Practice Address - City:EAST PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02914-1430
Practice Address - Country:US
Practice Address - Phone:401-421-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-16
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RICDP00481101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
RICDP00481OtherLICENSE