Provider Demographics
NPI:1578576534
Name:WHITNEY, MARK EDWARD (LCSW)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:EDWARD
Last Name:WHITNEY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2446 NW HUMMINGBIRD DR
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-2280
Mailing Address - Country:US
Mailing Address - Phone:208-477-7194
Mailing Address - Fax:
Practice Address - Street 1:2446 NW HUMMINGBIRD DR
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-2280
Practice Address - Country:US
Practice Address - Phone:208-477-7194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
IDLCSW-3197104100000X
WALW60169256104100000X
ORL8340104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500775581Medicaid