Healthcare Provider Details

I. General information

NPI: 1720622723
Provider Name (Legal Business Name): STEPHEN PAUL WHITAKER MA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2019
Last Update Date: 02/02/2024
Certification Date: 02/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1409 HIGHWAY 3057
SOMERSET KY
42501-3363
US

IV. Provider business mailing address

1409 HIGHWAY 3057
SOMERSET KY
42501-3363
US

V. Phone/Fax

Practice location:
  • Phone: 404-955-7796
  • Fax:
Mailing address:
  • Phone: 404-955-7796
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number289579
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: