Provider Demographics
NPI:1275260135
Name:WHITESIDE, MCKENNA
Entity Type:Individual
Prefix:
First Name:MCKENNA
Middle Name:
Last Name:WHITESIDE
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 1:88 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034-1415
Mailing Address - Country:US
Mailing Address - Phone:618-288-8085
Mailing Address - Fax:314-288-8959
Practice Address - Street 1:88 S MAIN ST
Practice Address - Street 2:
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034-1415
Practice Address - Country:US
Practice Address - Phone:618-288-8085
Practice Address - Fax:618-288-8959
Is Sole Proprietor?:No
Enumeration Date:2022-08-02
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4A00-IPI-032Medicaid