Provider Demographics
NPI:1124361308
Name:KANTACK, WHITNEY (PHD, LP)
Entity Type:Individual
Prefix:
First Name:WHITNEY
Middle Name:
Last Name:KANTACK
Suffix:
Gender:F
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2075 W BIG BEAVER RD
Mailing Address - Street 2:SUITE 520
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-3407
Mailing Address - Country:US
Mailing Address - Phone:248-646-6659
Mailing Address - Fax:
Practice Address - Street 1:2075 W BIG BEAVER RD
Practice Address - Street 2:SUITE 520
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-3407
Practice Address - Country:US
Practice Address - Phone:248-646-6659
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-05
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301015876103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical