Provider Demographics
NPI:1407331135
Name:WHITEHURST, DEMEITRIUS M (BA, CSAC, QMHP-A-C)
Entity Type:Individual
Prefix:
First Name:DEMEITRIUS
Middle Name:M
Last Name:WHITEHURST
Suffix:
Gender:M
Credentials:BA, CSAC, QMHP-A-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12388 WARWICK BLVD STE 302
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-3858
Mailing Address - Country:US
Mailing Address - Phone:757-679-6058
Mailing Address - Fax:
Practice Address - Street 1:12388 WARWICK BLVD STE 302, NEWPORT NEWS, VA 23602
Practice Address - Street 2:STE 302
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23606-2360
Practice Address - Country:US
Practice Address - Phone:757-679-6058
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-27
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0710102215101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000000OtherNONE