Provider Demographics
NPI:1114639903
Name:HERNDON, WHITLEY
Entity Type:Individual
Prefix:
First Name:WHITLEY
Middle Name:
Last Name:HERNDON
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:PO BOX 15555
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80935-5555
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7353 SISTERS GRV
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80923-2615
Practice Address - Country:US
Practice Address - Phone:888-235-9475
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-23
Last Update Date:2022-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACD.0002162101YP2500X
COLPC.0018825101YP2500X
ACD.0002162101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)