Provider Demographics
NPI:1174857619
Name:WALLACE, WHITNEY ANTIA
Entity Type:Individual
Prefix:MISS
First Name:WHITNEY
Middle Name:ANTIA
Last Name:WALLACE
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 1:2900 CHAUTAUQUA AVE
Mailing Address - Street 2:#207
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73072-7723
Mailing Address - Country:US
Mailing Address - Phone:940-597-9459
Mailing Address - Fax:
Practice Address - Street 1:900 E MAIN ST
Practice Address - Street 2:BUILDING 52 UNIT 200
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73071-5305
Practice Address - Country:US
Practice Address - Phone:405-307-4800
Practice Address - Fax:405-307-4828
Is Sole Proprietor?:No
Enumeration Date:2009-10-01
Last Update Date:2009-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health