Provider Demographics
NPI:1528606266
Name:WHITLEY, MICHAEL (PMHNP)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:WHITLEY
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:83 BERDAN ST
Mailing Address - Street 2:
Mailing Address - City:ROCHELLE PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07662-3724
Mailing Address - Country:US
Mailing Address - Phone:347-466-6733
Mailing Address - Fax:
Practice Address - Street 1:7 CROTON AVE
Practice Address - Street 2:
Practice Address - City:CORTLANDT MANOR
Practice Address - State:NY
Practice Address - Zip Code:10567-5203
Practice Address - Country:US
Practice Address - Phone:914-962-5800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-12
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY405634363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health