Provider Demographics
NPI:1679821987
Name:WHITAKER, SALLY ANN (LPC)
Entity Type:Individual
Prefix:MS
First Name:SALLY
Middle Name:ANN
Last Name:WHITAKER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 47
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83308
Mailing Address - Country:US
Mailing Address - Phone:208-732-0995
Mailing Address - Fax:208-732-0993
Practice Address - Street 1:493 EASTLAND DR.
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83303
Practice Address - Country:US
Practice Address - Phone:208-732-0995
Practice Address - Fax:208-732-0993
Is Sole Proprietor?:No
Enumeration Date:2012-08-16
Last Update Date:2015-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-5090101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health