MEDICARE: RENE WHITEHEAD MS, LCAS-A

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	29437	NC

General Provider Information

NPI Number	:	1255105185
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RENE WHITEHEAD MS, LCAS-A

Provider Business Mailing Address
First Line	:	355 BECKWITH AVE
Second Line	:
City	:	CLAYTON
State	:	NC
Zip	:	27527-4258
Country	:	US
Telephone Number	:	919-538-8920
Fax Number	:

Provider Business Practice Location Address
First Line	:	355 BECKWITH AVE
Second Line	:
City	:	CLAYTON
State	:	NC
Zip	:	27527-4258
Country	:	US
Telephone Number	:	919-538-8920
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/10/2023
Last Update Date	:	11/10/2023

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