Provider Demographics
NPI:1508553645
Name:WHITTHORNE, LANISE (RA163110)
Entity Type:Individual
Prefix:
First Name:LANISE
Middle Name:
Last Name:WHITTHORNE
Suffix:
Gender:F
Credentials:RA163110
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:665 W MARKET ST
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44303-1438
Mailing Address - Country:US
Mailing Address - Phone:330-379-3467
Mailing Address - Fax:330-379-3465
Practice Address - Street 1:665 W MARKET ST
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44303-1438
Practice Address - Country:US
Practice Address - Phone:330-379-3467
Practice Address - Fax:330-379-3465
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-19
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRA.163110405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional