Provider Demographics
NPI:1912563206
Name:WHITAKER, MATTHEW
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
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 1:4919 CANAL ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70119-5848
Mailing Address - Country:US
Mailing Address - Phone:504-483-9883
Mailing Address - Fax:
Practice Address - Street 1:431 W LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:WINNFIELD
Practice Address - State:LA
Practice Address - Zip Code:71483-3463
Practice Address - Country:US
Practice Address - Phone:318-648-0375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-13
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPLC7765171M00000X
LA7765101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator