Provider Demographics
NPI:1922212604
Name:WHITEHEAD, ALWYN S JR (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ALWYN
Middle Name:S
Last Name:WHITEHEAD
Suffix:JR
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:ALWYN
Other - Middle Name:S
Other - Last Name:WHITEHEAD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:6920 BANCROFT AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63109-1902
Mailing Address - Country:US
Mailing Address - Phone:417-234-1670
Mailing Address - Fax:
Practice Address - Street 1:6920 BANCROFT AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63109-1902
Practice Address - Country:US
Practice Address - Phone:417-234-1670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002011127103T00000X, 103TF0200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO43-1804357OtherTAX ID