Provider Demographics
NPI:1619675154
Name:WHITLOCK FAMILY & MARRIAGE THERAPY
Entity Type:Organization
Organization Name:WHITLOCK FAMILY & MARRIAGE THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/ PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:ARIEL
Authorized Official - Middle Name:KRYSTA
Authorized Official - Last Name:WHITLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:775-351-9411
Mailing Address - Street 1:1624 SANTA CLARA DR STE 110
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-3553
Mailing Address - Country:US
Mailing Address - Phone:775-287-8807
Mailing Address - Fax:
Practice Address - Street 1:1624 SANTA CLARA DR STE 110
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3553
Practice Address - Country:US
Practice Address - Phone:775-287-8807
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-22
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)