Provider Demographics
NPI:1780838557
Name:WHITAKER, KATHLEEN M (CNS)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:M
Last Name:WHITAKER
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 W. NORTH ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:IN
Mailing Address - Zip Code:46052
Mailing Address - Country:US
Mailing Address - Phone:765-481-2015
Mailing Address - Fax:765-481-2270
Practice Address - Street 1:209 W NORTH ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:IN
Practice Address - Zip Code:46052
Practice Address - Country:US
Practice Address - Phone:765-481-2015
Practice Address - Fax:765-481-2270
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-06
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN70000213364SP0808X, 364S00000X
IN28056006A163WP0808X, 163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
No364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200983160Medicaid