Provider Demographics
NPI:1033887054
Name:WHITESIDE, MICHAEL DWAYNE II
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DWAYNE
Last Name:WHITESIDE
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 S CLARK ST APT 722
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22202-4059
Mailing Address - Country:US
Mailing Address - Phone:317-654-3078
Mailing Address - Fax:
Practice Address - Street 1:3400 S CLARK ST APT 722
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22202-4059
Practice Address - Country:US
Practice Address - Phone:317-654-3078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-03
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99105879A1041C0700X
VA09040154301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty