Provider Demographics
NPI:1831475946
Name:WHITAKER, ANGELA (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:WHITAKER
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2076 SCHOOL LN
Mailing Address - Street 2:
Mailing Address - City:SOUTHSIDE
Mailing Address - State:TN
Mailing Address - Zip Code:37171-9133
Mailing Address - Country:US
Mailing Address - Phone:865-773-4292
Mailing Address - Fax:
Practice Address - Street 1:161 HATCHER LN
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-5987
Practice Address - Country:US
Practice Address - Phone:931-542-2168
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-02
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3480235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist