Provider Demographics
NPI:1740753680
Name:WHITEHEAD, DETRICK DEVON
Entity Type:Individual
Prefix:
First Name:DETRICK
Middle Name:DEVON
Last Name:WHITEHEAD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 224
Mailing Address - Street 2:
Mailing Address - City:SNYDER
Mailing Address - State:OK
Mailing Address - Zip Code:73566-0224
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:307 1/2 2ND ST
Practice Address - Street 2:
Practice Address - City:SNYDER
Practice Address - State:OK
Practice Address - Zip Code:73566-1215
Practice Address - Country:US
Practice Address - Phone:580-678-0847
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-03
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKM082104066171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator