Provider Demographics
NPI:1710585880
Name:WHITEHEAD, DARRYL XAVIER (CEO)
Entity Type:Individual
Prefix:
First Name:DARRYL
Middle Name:XAVIER
Last Name:WHITEHEAD
Suffix:
Gender:M
Credentials:CEO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3455 WILKENS AVE STE 301
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21229-5214
Mailing Address - Country:US
Mailing Address - Phone:443-682-8398
Mailing Address - Fax:443-562-1161
Practice Address - Street 1:3455 WILKENS AVE STE 301
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21229-5214
Practice Address - Country:US
Practice Address - Phone:443-682-8398
Practice Address - Fax:443-562-1161
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-12
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health