Provider Demographics
NPI:1073893657
Name:WHITTAKER, MICHAEL ANTHONY (MFT INTERN)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:WHITTAKER
Suffix:
Gender:M
Credentials:MFT INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90017-1908
Mailing Address - Country:US
Mailing Address - Phone:805-428-2164
Mailing Address - Fax:
Practice Address - Street 1:1200 WILSHIRE BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-1908
Practice Address - Country:US
Practice Address - Phone:805-428-2164
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-26
Last Update Date:2016-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF67430106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist