Healthcare Provider Details

I. General information

NPI: 1962910216
Provider Name (Legal Business Name): TAMIA WHITESIDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2018
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 AYERS CIR
SUMMERVILLE SC
29485-3303
US

IV. Provider business mailing address

181 W PROFESSIONAL PARK CT STE 1
BOWLING GREEN KY
42104-3250
US

V. Phone/Fax

Practice location:
  • Phone: 843-460-2605
  • Fax: 888-298-0519
Mailing address:
  • Phone: 270-777-9283
  • Fax: 270-777-9283

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number17-35253
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: