Healthcare Provider Details

I. General information

NPI: 1124772413
Provider Name (Legal Business Name): MARC DANIEL WHITTLESAY JR. LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2022
Last Update Date: 02/07/2022
Certification Date: 02/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5897 LITTLE LEAF CT
MILTON FL
32570-3501
US

IV. Provider business mailing address

5897 LITTLE LEAF CT
MILTON FL
32570-3501
US

V. Phone/Fax

Practice location:
  • Phone: 850-490-7829
  • Fax:
Mailing address:
  • Phone: 850-490-7829
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH16713
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: