Provider Demographics
NPI:1689852709
Name:WHITLOCK, BRIAN KEITH (PHD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:KEITH
Last Name:WHITLOCK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 W 2ND ST
Mailing Address - Street 2:SUITE 10
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-4670
Mailing Address - Country:US
Mailing Address - Phone:575-623-9322
Mailing Address - Fax:575-627-6339
Practice Address - Street 1:601 W 2ND ST
Practice Address - Street 2:SUITE 10
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-4670
Practice Address - Country:US
Practice Address - Phone:575-623-9322
Practice Address - Fax:575-627-6339
Is Sole Proprietor?:No
Enumeration Date:2008-01-31
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0966103TH0100X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical