Provider Demographics
NPI:1275543738
Name:WHITLEY, DONALD MAURICE II (PHD)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:MAURICE
Last Name:WHITLEY
Suffix:II
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1598 DELPHIC WAY
Mailing Address - Street 2:SUITE A-1
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-2285
Mailing Address - Country:US
Mailing Address - Phone:208-233-4900
Mailing Address - Fax:208-233-4373
Practice Address - Street 1:1598 DELPHIC WAY
Practice Address - Street 2:SUITE A-1
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2285
Practice Address - Country:US
Practice Address - Phone:208-233-4900
Practice Address - Fax:208-233-4373
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY 418103TC0700X
UT4839092-2501103TC0700X
GA1804103TC0700X
FL2689103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1684891Medicare ID - Type Unspecified