Provider Demographics
NPI:1437242773
Name:WITHERSPOON, KIRK (PHD)
Entity Type:Individual
Prefix:DR
First Name:KIRK
Middle Name:
Last Name:WITHERSPOON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:722 23RD AVENUE CT
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-4624
Mailing Address - Country:US
Mailing Address - Phone:309-762-2922
Mailing Address - Fax:309-762-8394
Practice Address - Street 1:722 23RD AVENUE CT
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-4624
Practice Address - Country:US
Practice Address - Phone:309-762-2922
Practice Address - Fax:309-762-8394
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL71-2839103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL734131-68Medicare ID - Type UnspecifiedPSYCHOLOGIST