Provider Demographics
NPI:1316414089
Name:WHITELY, PHILLIP (CDCA, PRS)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:WHITELY
Suffix:
Gender:M
Credentials:CDCA, PRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:433 3RD ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-3811
Mailing Address - Country:US
Mailing Address - Phone:740-716-8746
Mailing Address - Fax:
Practice Address - Street 1:411 2ND ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-3806
Practice Address - Country:US
Practice Address - Phone:740-354-7545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-31
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
OH0001602175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)