=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376931907
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TEJUANDA SHANTA WHITEHEAD SR. MPA,BSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/06/2015
-----------------------------------------------------
Last Update Date | 01/06/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 217 TREMONT AVE
-----------------------------------------------------
City | ALBANY
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31701-5707
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-364-9026
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 217 TREMONT AVE
-----------------------------------------------------
City | ALBANY
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31701-5707
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-364-9026
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 053681248
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------