Provider Demographics
NPI:1639437551
Name:WHITAKER, IESHA NATE (LMSW)
Entity Type:Individual
Prefix:
First Name:IESHA
Middle Name:NATE
Last Name:WHITAKER
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 CENTRAL AVE
Mailing Address - Street 2:FLOOR 1
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-4000
Mailing Address - Country:US
Mailing Address - Phone:718-471-6818
Mailing Address - Fax:
Practice Address - Street 1:1600 CENTRAL AVE
Practice Address - Street 2:FLOOR 1
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-4000
Practice Address - Country:US
Practice Address - Phone:718-471-6818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-28
Last Update Date:2012-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY085854104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker