Provider Demographics
NPI:1407066855
Name:WHITLEY, GLORIA SMITH (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:GLORIA
Middle Name:SMITH
Last Name:WHITLEY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 31234
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39286-1234
Mailing Address - Country:US
Mailing Address - Phone:601-201-4189
Mailing Address - Fax:
Practice Address - Street 1:405 BRIARWOOD DR
Practice Address - Street 2:BUILDINGA SUITE 106-E
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39206-3052
Practice Address - Country:US
Practice Address - Phone:601-991-3156
Practice Address - Fax:601-991-3157
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSCO793101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health