Provider Demographics
NPI:1619225125
Name:WHITAKER, BRANDI NICOLE (PHD)
Entity Type:Individual
Prefix:
First Name:BRANDI
Middle Name:NICOLE
Last Name:WHITAKER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:BRANDI
Other - Middle Name:NICOLE
Other - Last Name:YOUNG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1 CHILDREN'S WAY
Mailing Address - Street 2:SLOT 512-21
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72202-3591
Mailing Address - Country:US
Mailing Address - Phone:501-364-1021
Mailing Address - Fax:
Practice Address - Street 1:1 CHILDRENS WAY
Practice Address - Street 2:SLOT 512-21
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72202-3500
Practice Address - Country:US
Practice Address - Phone:501-364-1021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-15
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR12-14P103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist