Healthcare Provider Details

I. General information

NPI: 1447607395
Provider Name (Legal Business Name): THERESA A. WHITTAKER LGSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2016
Last Update Date: 05/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

908 SCARBRO RD
SCARBRO WV
25917-8837
US

IV. Provider business mailing address

908 SCARBRO RD P
SCARBRO WV
25917-8837
US

V. Phone/Fax

Practice location:
  • Phone: 304-469-2905
  • Fax: 304-465-5486
Mailing address:
  • Phone: 304-574-2905
  • Fax: 304-465-5486

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberBP00942748
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: