Provider Demographics
NPI:1417965583
Name:WHITACRE, EDWARD JOHN (LCSW)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:JOHN
Last Name:WHITACRE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4657 MASSENA DR
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23188-1261
Mailing Address - Country:US
Mailing Address - Phone:757-566-4824
Mailing Address - Fax:
Practice Address - Street 1:11825 ROCK LANDING DR
Practice Address - Street 2:THE JAMES BUILDING
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-4236
Practice Address - Country:US
Practice Address - Phone:757-873-1736
Practice Address - Fax:757-873-1028
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040023901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical