Provider Demographics
NPI:1740758168
Name:WHITAKER, WILLIAM (AAS, BA, MED)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:WHITAKER
Suffix:
Gender:M
Credentials:AAS, BA, MED
Other - Prefix:
Other - First Name:WILLIAM
Other - Middle Name:ISAIAH
Other - Last Name:WHITAKER
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1115 E SANGER ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19124-1130
Mailing Address - Country:US
Mailing Address - Phone:267-461-1813
Mailing Address - Fax:
Practice Address - Street 1:1115 E SANGER ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19124-1130
Practice Address - Country:US
Practice Address - Phone:267-461-1813
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-02
Last Update Date:2018-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA174400000X, 106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No174400000XOther Service ProvidersSpecialist