Provider Demographics
NPI:1447607395
Name:WHITTAKER, THERESA A (LGSW)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:A
Last Name:WHITTAKER
Suffix:
Gender:F
Credentials:LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:908 SCARBRO RD
Mailing Address - Street 2:P
Mailing Address - City:SCARBRO
Mailing Address - State:WV
Mailing Address - Zip Code:25917-8837
Mailing Address - Country:US
Mailing Address - Phone:304-574-2905
Mailing Address - Fax:304-465-5486
Practice Address - Street 1:908 SCARBRO RD
Practice Address - Street 2:
Practice Address - City:SCARBRO
Practice Address - State:WV
Practice Address - Zip Code:25917-8837
Practice Address - Country:US
Practice Address - Phone:304-469-2905
Practice Address - Fax:304-465-5486
Is Sole Proprietor?:No
Enumeration Date:2016-05-20
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVBP00942748104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker