Healthcare Provider Details

I. General information

NPI: 1609412246
Provider Name (Legal Business Name): SHENIKA LAVONDA WHITAKER-CARLOS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2019
Last Update Date: 03/03/2020
Certification Date: 03/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4118 E PARHAM RD STE A
RICHMOND VA
23228-2742
US

IV. Provider business mailing address

6933 COMMONS PLZ # 249
CHESTERFIELD VA
23832-6457
US

V. Phone/Fax

Practice location:
  • Phone: 804-591-0002
  • Fax:
Mailing address:
  • Phone: 804-503-8487
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904008931
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: