Provider Demographics
NPI:1568608024
Name:WHITEHEAD, MATTHEW L (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:L
Last Name:WHITEHEAD
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 N JACKSON ST APT 3A
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-2818
Mailing Address - Country:US
Mailing Address - Phone:610-566-8357
Mailing Address - Fax:
Practice Address - Street 1:255 S 17TH ST
Practice Address - Street 2:SUITE 2510
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19103-6231
Practice Address - Country:US
Practice Address - Phone:610-566-8357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-05
Last Update Date:2009-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS016572103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical