Provider Demographics
NPI:1437364783
Name:WHITLEY, MICHAEL W (LCAS)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:W
Last Name:WHITLEY
Suffix:
Gender:M
Credentials:LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 N ORANGE AVE
Mailing Address - Street 2:
Mailing Address - City:DUNN
Mailing Address - State:NC
Mailing Address - Zip Code:28334-3826
Mailing Address - Country:US
Mailing Address - Phone:910-891-7062
Mailing Address - Fax:910-892-3764
Practice Address - Street 1:133 W CORNELIUS-HARNETT BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:LILLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27546-7854
Practice Address - Country:US
Practice Address - Phone:910-814-0394
Practice Address - Fax:910-814-1426
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC23101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC23OtherLCAS
NC6111840Medicaid