Provider Demographics
NPI:1275230385
Name:WITHERSPOON, MAYA JENELLE
Entity Type:Individual
Prefix:
First Name:MAYA
Middle Name:JENELLE
Last Name:WITHERSPOON
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 1:4900 MERIDIAN ST N
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35811-1156
Mailing Address - Country:US
Mailing Address - Phone:256-372-8478
Mailing Address - Fax:
Practice Address - Street 1:4900 MERIDIAN ST N
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35811-1156
Practice Address - Country:US
Practice Address - Phone:256-372-8478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-09
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL8609875104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL8609875Medicaid