Provider Demographics
NPI:1962678961
Name:WHITLOCK, SHERI LEN
Entity Type:Individual
Prefix:
First Name:SHERI
Middle Name:LEN
Last Name:WHITLOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11406 BALM RIVERVIEW RD
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33569-6215
Mailing Address - Country:US
Mailing Address - Phone:813-671-2833
Mailing Address - Fax:813-671-2833
Practice Address - Street 1:11406 BALM RIVERVIEW RD
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33569-6215
Practice Address - Country:US
Practice Address - Phone:813-671-2833
Practice Address - Fax:813-671-2833
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-30
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL230489900253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL230489900Medicaid