Healthcare Provider Details

I. General information

NPI: 1396857322
Provider Name (Legal Business Name): DIANE LOUISE WHITEHEAD PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

607 BAXTER ST FAIRVIEW ASS.
JOHNSON CITY TN
37601
US

IV. Provider business mailing address

PO BOX 9054
GRAY TN
37615-9054
US

V. Phone/Fax

Practice location:
  • Phone: 423-232-2670
  • Fax: 423-928-0381
Mailing address:
  • Phone: 423-467-3600
  • Fax: 423-467-3696

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPHD 425
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: