Provider Demographics
NPI:1740581438
Name:WHITTAKER, DEANNA LYN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:DEANNA
Middle Name:LYN
Last Name:WHITTAKER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:DEANNA
Other - Middle Name:LYN
Other - Last Name:HOLEMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:402 S SILVER SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-7536
Mailing Address - Country:US
Mailing Address - Phone:573-334-1100
Mailing Address - Fax:573-651-4345
Practice Address - Street 1:402 S SILVER SPRINGS RD
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-7536
Practice Address - Country:US
Practice Address - Phone:573-334-1100
Practice Address - Fax:573-651-4345
Is Sole Proprietor?:No
Enumeration Date:2010-11-11
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20120075031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO490000856Medicaid