Provider Demographics
NPI:1639112238
Name:ANDERSEN-WHITEHURST, MARIE
Entity Type:Individual
Prefix:MS
First Name:MARIE
Middle Name:
Last Name:ANDERSEN-WHITEHURST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5729 OLD RANDLEMAN RD
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27406-8808
Mailing Address - Country:US
Mailing Address - Phone:336-632-3505
Mailing Address - Fax:336-665-6188
Practice Address - Street 1:5729 OLD RANDLEMAN RD
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27406-8808
Practice Address - Country:US
Practice Address - Phone:336-632-3505
Practice Address - Fax:336-665-6188
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2015-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0011721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8911249Medicaid
NC8911249Medicaid