Provider Demographics
NPI:1437405750
Name:WHITTAKER, EDWARD WESLEY (LADC)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:WESLEY
Last Name:WHITTAKER
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8015 36TH AVE N APT 217
Mailing Address - Street 2:
Mailing Address - City:NEW HOPE
Mailing Address - State:MN
Mailing Address - Zip Code:55427-1960
Mailing Address - Country:US
Mailing Address - Phone:612-636-0801
Mailing Address - Fax:
Practice Address - Street 1:8015 36TH AVE N APT 217
Practice Address - Street 2:
Practice Address - City:NEW HOPE
Practice Address - State:MN
Practice Address - Zip Code:55427-1960
Practice Address - Country:US
Practice Address - Phone:612-636-0801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-24
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN300517101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)