Provider Demographics
NPI:1023079696
Name:WHITTAKER, MARY ELIZABETH (LCSW)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:WHITTAKER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MARY BETH
Other - Middle Name:
Other - Last Name:WHITTAKER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:970 MURRAY HOLLADAY RD
Mailing Address - Street 2:#2F
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-4962
Mailing Address - Country:US
Mailing Address - Phone:801-264-9960
Mailing Address - Fax:801-264-5099
Practice Address - Street 1:970 MURRAY HOLLADAY RD
Practice Address - Street 2:#2F
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84117-4962
Practice Address - Country:US
Practice Address - Phone:801-264-9960
Practice Address - Fax:801-264-5099
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT130283-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical