Provider Demographics
NPI:1679001127
Name:DICKENS, WHITNEY VONSHEA (BACHELORS)
Entity Type:Individual
Prefix:MS
First Name:WHITNEY
Middle Name:VONSHEA
Last Name:DICKENS
Suffix:
Gender:F
Credentials:BACHELORS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2128 SIMMONS AVE
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-3797
Mailing Address - Country:US
Mailing Address - Phone:407-492-4107
Mailing Address - Fax:
Practice Address - Street 1:3850 W ANTHONY RD
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34475
Practice Address - Country:US
Practice Address - Phone:321-241-1170
Practice Address - Fax:321-241-1171
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-30
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL18-62535106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017475600Medicaid