Provider Demographics
NPI:1275093304
Name:WHITLEY, MARISA (PHD)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:WHITLEY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9217 PARK WEST BLVD STE D1
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37923-4420
Mailing Address - Country:US
Mailing Address - Phone:865-691-2425
Mailing Address - Fax:
Practice Address - Street 1:9217 PARK WEST BLVD STE D1
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923-4420
Practice Address - Country:US
Practice Address - Phone:865-691-2425
Practice Address - Fax:865-531-8440
Is Sole Proprietor?:No
Enumeration Date:2019-03-24
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3753103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical