Provider Demographics
NPI:1275139933
Name:WHITAKER, DESEREE PASSION
Entity Type:Individual
Prefix:MRS
First Name:DESEREE
Middle Name:PASSION
Last Name:WHITAKER
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 1:238 N BLACKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ZANESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43701-4658
Mailing Address - Country:US
Mailing Address - Phone:740-408-2801
Mailing Address - Fax:
Practice Address - Street 1:238 N BLACKWOOD DR
Practice Address - Street 2:
Practice Address - City:ZANESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43701-4658
Practice Address - Country:US
Practice Address - Phone:740-408-2801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-08
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH103100268499Medicaid