Provider Demographics
NPI:1164110433
Name:WHETSTONE, CHARNISE IVORY
Entity Type:Individual
Prefix:
First Name:CHARNISE
Middle Name:IVORY
Last Name:WHETSTONE
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 1:33125 WARREN RD APT 218
Mailing Address - Street 2:
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48185-2924
Mailing Address - Country:US
Mailing Address - Phone:567-998-2088
Mailing Address - Fax:
Practice Address - Street 1:33125 WARREN RD APT 218
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185-2924
Practice Address - Country:US
Practice Address - Phone:567-998-2088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-25
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician