Provider Demographics
NPI:1891563169
Name:WHITAKER, SKYLAR
Entity Type:Individual
Prefix:
First Name:SKYLAR
Middle Name:
Last Name:WHITAKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:RHETT
Other - Middle Name:
Other - Last Name:WHITAKER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5554 RESEDA BLVD STE 203
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-6212
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6004 WALDEN DR
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37919-6337
Practice Address - Country:US
Practice Address - Phone:865-766-5775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-18
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician