Provider Demographics
NPI:1013408137
Name:WHITESIDE, MARA ELIZABETH (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARA
Middle Name:ELIZABETH
Last Name:WHITESIDE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:MARA
Other - Middle Name:ELIZABETH
Other - Last Name:WOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:2575 S. GENE GEORGE BLVD
Mailing Address - Street 2:STE. 100
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72762
Mailing Address - Country:US
Mailing Address - Phone:479-750-0125
Mailing Address - Fax:
Practice Address - Street 1:2575 S. GENE GEORGE BLVD.
Practice Address - Street 2:STE. 100
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72762
Practice Address - Country:US
Practice Address - Phone:479-750-0125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-24
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR17-24P103T00000X, 103TS0200X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool