Provider Demographics
NPI:1346880341
Name:WHITEHEAD, DEMETRIUS (LPN)
Entity Type:Individual
Prefix:
First Name:DEMETRIUS
Middle Name:
Last Name:WHITEHEAD
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 S BUTLER AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-7034
Mailing Address - Country:US
Mailing Address - Phone:317-409-1422
Mailing Address - Fax:
Practice Address - Street 1:415 S BUTLER AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-7034
Practice Address - Country:US
Practice Address - Phone:317-499-0437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-08
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN27060564A164W00000X
IN21015321320600000X, 320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
No164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Multi-Specialty
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities