Provider Demographics
NPI:1710433354
Name:WHITTAKER, PAULEETTA LYNN (MS, LMHCA)
Entity Type:Individual
Prefix:
First Name:PAULEETTA
Middle Name:LYNN
Last Name:WHITTAKER
Suffix:
Gender:F
Credentials:MS, LMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 8TH ST UNIT A
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32080-6351
Mailing Address - Country:US
Mailing Address - Phone:317-443-5928
Mailing Address - Fax:386-256-1761
Practice Address - Street 1:4721 E MOODY BLVD STE 204
Practice Address - Street 2:
Practice Address - City:BUNNELL
Practice Address - State:FL
Practice Address - Zip Code:32110-7706
Practice Address - Country:US
Practice Address - Phone:386-793-9669
Practice Address - Fax:386-256-1761
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-01
Last Update Date:2019-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH17090101YM0800X
IN101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201359450Medicaid