Healthcare Provider Details

I. General information

NPI: 1730165978
Provider Name (Legal Business Name): DOUGLAS LYNN WHITTAKER LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/20/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7434 S STATE ST
MIDVALE UT
84047-2014
US

IV. Provider business mailing address

4084 FOUBERT AVE
SALT LAKE CITY UT
84124-3411
US

V. Phone/Fax

Practice location:
  • Phone: 801-566-4423
  • Fax: 801-566-4779
Mailing address:
  • Phone: 801-278-7453
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number126368-3501
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier94293834BLYN
Identifier TypeOTHER
Identifier StateUT
Identifier IssuerEDUCATORS MUTUAL
# 2
Identifier107032362101
Identifier TypeOTHER
Identifier StateUT
Identifier IssuerINTRMTN. HEALTH CARE
# 3
Identifier827403
Identifier TypeOTHER
Identifier StateUT
Identifier IssuerDESERET MUTUAL
# 4
Identifier942938348003
Identifier TypeOTHER
Identifier StateUT
Identifier IssuerCHAMPUS
# 5
IdentifierR88031
Identifier TypeOTHER
Identifier StateUT
Identifier IssuerMEDICARE ADVANAGE PLANS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: