Provider Demographics
NPI:1689218166
Name:WHITAKER, KIERSTEN
Entity Type:Individual
Prefix:
First Name:KIERSTEN
Middle Name:
Last Name:WHITAKER
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 1:10014 N DALE MBRY HWY STE C-100
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33618-4426
Mailing Address - Country:US
Mailing Address - Phone:800-356-4049
Mailing Address - Fax:
Practice Address - Street 1:10014 N DALE MBRY HWY STE C-100
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-4426
Practice Address - Country:US
Practice Address - Phone:800-356-4049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-29
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician