Provider Demographics
NPI:1295863629
Name:WHITELOCKE, LUCY ANN (MS)
Entity Type:Individual
Prefix:
First Name:LUCY
Middle Name:ANN
Last Name:WHITELOCKE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:LUCY
Other - Middle Name:
Other - Last Name:MCPHERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MT 2646
Mailing Address - Street 1:11193 NW 37TH ST
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33351-7581
Mailing Address - Country:US
Mailing Address - Phone:954-610-0450
Mailing Address - Fax:
Practice Address - Street 1:120 S UNIVERSITY DR STE F
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33324-3346
Practice Address - Country:US
Practice Address - Phone:954-610-0450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
FLMT 2646101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL764991600Medicaid