MEDICARE: DR. JOHN CALVIN WHITLEY III PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	1922	GA
2	103TC0700X	Clinical Psychologist	625	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1184607483
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN CALVIN WHITLEY III PH.D.

Provider Business Mailing Address
First Line	:	2828 HILLCREEK DR
Second Line	:
City	:	AUGUSTA
State	:	GA
Zip	:	30909-5628
Country	:	US
Telephone Number	:	706-228-5006
Fax Number	:	706-228-1848

Provider Business Practice Location Address
First Line	:	2828 HILLCREEK DR
Second Line	:
City	:	AUGUSTA
State	:	GA
Zip	:	30909-5628
Country	:	US
Telephone Number	:	706-228-5006
Fax Number	:	706-228-1848

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/21/2005
Last Update Date	:	07/08/2007

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