Provider Demographics
NPI:1619468501
Name:WHITEHEAD, AISHAH RENEE (LCSWA)
Entity Type:Individual
Prefix:
First Name:AISHAH
Middle Name:RENEE
Last Name:WHITEHEAD
Suffix:
Gender:F
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:419 TYLER TRAIL CT APT 222
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-3393
Mailing Address - Country:US
Mailing Address - Phone:770-895-7580
Mailing Address - Fax:
Practice Address - Street 1:5200 PARK RD STE 218B
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209-3650
Practice Address - Country:US
Practice Address - Phone:866-700-1606
Practice Address - Fax:866-338-5921
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-25
Last Update Date:2018-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0113941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical