Provider Demographics
NPI:1790374585
Name:WHITAKER, DARCELL LANIER
Entity Type:Individual
Prefix:
First Name:DARCELL
Middle Name:LANIER
Last Name:WHITAKER
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 1:1610 GLENDALE ST
Mailing Address - Street 2:
Mailing Address - City:HOPEWELL
Mailing Address - State:VA
Mailing Address - Zip Code:23860-6922
Mailing Address - Country:US
Mailing Address - Phone:804-312-6883
Mailing Address - Fax:
Practice Address - Street 1:1610 GLENDALE ST
Practice Address - Street 2:
Practice Address - City:HOPEWELL
Practice Address - State:VA
Practice Address - Zip Code:23860-6922
Practice Address - Country:US
Practice Address - Phone:804-312-6883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-15
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA3593-01-001320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities