Provider Demographics
NPI:1053041467
Name:WHITEAKER, ALYSSA MARIE (LICSW)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:MARIE
Last Name:WHITEAKER
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 KELLOGG BLVD E APT 708
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55101-1206
Mailing Address - Country:US
Mailing Address - Phone:651-800-1302
Mailing Address - Fax:
Practice Address - Street 1:111 KELLOGG BLVD E APT 708
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101-1206
Practice Address - Country:US
Practice Address - Phone:651-800-1302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-16
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN248951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical