Provider Demographics
NPI:1689132987
Name:WHITTINGTON, JOSEPH MATTHEW
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:MATTHEW
Last Name:WHITTINGTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:271 BERKLEY DR
Mailing Address - Street 2:
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-2411
Mailing Address - Country:US
Mailing Address - Phone:256-624-0374
Mailing Address - Fax:
Practice Address - Street 1:523 DIXIE ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3870
Practice Address - Country:US
Practice Address - Phone:770-812-8343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-05
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC010819101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional