Healthcare Provider Details

I. General information

NPI: 1063400851
Provider Name (Legal Business Name): RICHARD R WHITTLESEY PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2005
Last Update Date: 04/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4601 CORBETT DR
FORT COLLINS CO
80528-9579
US

IV. Provider business mailing address

4601 CORBETT DR
FORT COLLINS CO
80528-9579
US

V. Phone/Fax

Practice location:
  • Phone: 970-207-4800
  • Fax: 970-207-4885
Mailing address:
  • Phone: 970-207-4800
  • Fax: 970-207-4885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number00194
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number00072
License Number StateIA
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY.0003103
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: