Healthcare Provider Details

I. General information

NPI: 1700018553
Provider Name (Legal Business Name): KATHLEEN LOUISE WHITEHEAD LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2009
Last Update Date: 08/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3003 HIWAY 95 STE N-104
BULLHEAD CITY AZ
86442-7860
US

IV. Provider business mailing address

3003 HIWAY 95 STE N-104
BULLHEAD CITY AZ
86442-7860
US

V. Phone/Fax

Practice location:
  • Phone: 928-763-0250
  • Fax: 928-763-0271
Mailing address:
  • Phone: 928-763-0250
  • Fax: 928-763-0271

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number11149
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: