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General NPI Number Information
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NPI Number | 1548039100
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Entity Type | Individual
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Provider Name | JOEL TYLER WHITESIDE LPC
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Gender | Male
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Dates
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Enumeration Date | 12/25/2023
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Last Update Date | 02/21/2024
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Provider Practice Location Address
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Address Line | 10756 W BUCHANAN ST
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City | AVONDALE
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State | AZ
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Zip | 85323-5441
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Country | US
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Telephone | 360-703-7138
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Fax |
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Provider Business Mailing Address
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Address Line | 10756 W BUCHANAN ST
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City | AVONDALE
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State | AZ
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Zip | 85323-5441
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Country | US
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Telephone | 360-703-7138
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | LPC-22756
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License Number State | AZ
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 22756
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License Number State | AZ
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