Provider Demographics
NPI:1518222561
Name:WHITLEY, MICHAEL DAVID (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DAVID
Last Name:WHITLEY
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 1:2600 S GESSNER RD
Mailing Address - Street 2:SUITE 307
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77063-3200
Mailing Address - Country:US
Mailing Address - Phone:713-447-4056
Mailing Address - Fax:
Practice Address - Street 1:2600 S GESSNER RD
Practice Address - Street 2:SUITE 307
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77063-3200
Practice Address - Country:US
Practice Address - Phone:713-447-4056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-05
Last Update Date:2012-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22590103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical