Provider Demographics
NPI:1134327927
Name:WHITEHEAD, CALVIN DOUGLAS (LCSW)
Entity Type:Individual
Prefix:MR
First Name:CALVIN
Middle Name:DOUGLAS
Last Name:WHITEHEAD
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2411 PATRICK PL
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31601-7937
Mailing Address - Country:US
Mailing Address - Phone:313-806-1847
Mailing Address - Fax:
Practice Address - Street 1:2217 PINEVIEW DR
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-7316
Practice Address - Country:US
Practice Address - Phone:229-671-6611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-03
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0043561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACSW004356Medicaid
GACSW004356Medicaid