Provider Demographics
NPI:1114342060
Name:WHITAKER, TRICO
Entity Type:Individual
Prefix:
First Name:TRICO
Middle Name:
Last Name:WHITAKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6268 BERRY PATCH WAY
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89142-0970
Mailing Address - Country:US
Mailing Address - Phone:702-641-9884
Mailing Address - Fax:
Practice Address - Street 1:6268 BERRY PATCH WAY
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89142-0970
Practice Address - Country:US
Practice Address - Phone:702-641-9884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-03
Last Update Date:2014-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNV20121267098103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1710246921Medicaid