Provider Demographics
NPI:1689801573
Name:WHITAKER, SHARRON (LBSW, MS, ICP)
Entity Type:Individual
Prefix:
First Name:SHARRON
Middle Name:
Last Name:WHITAKER
Suffix:
Gender:F
Credentials:LBSW, MS, ICP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6969 PASTOR BAILEY DR
Mailing Address - Street 2:SUITE 140
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75237-2636
Mailing Address - Country:US
Mailing Address - Phone:972-298-3366
Mailing Address - Fax:214-920-8494
Practice Address - Street 1:6969 PASTOR BAILEY DR
Practice Address - Street 2:SUITE 140
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75237-2636
Practice Address - Country:US
Practice Address - Phone:972-298-3366
Practice Address - Fax:214-920-8494
Is Sole Proprietor?:No
Enumeration Date:2009-06-17
Last Update Date:2009-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX03903171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX171M00000XMedicaid