Provider Demographics
NPI:1124792346
Name:WHITTAKER, MOLLY
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:WHITTAKER
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 1:3517 NW 164TH TER
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-9471
Mailing Address - Country:US
Mailing Address - Phone:808-343-9757
Mailing Address - Fax:
Practice Address - Street 1:2248 NW 164TH ST
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-8801
Practice Address - Country:US
Practice Address - Phone:405-572-3776
Practice Address - Fax:405-562-3313
Is Sole Proprietor?:No
Enumeration Date:2021-08-02
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician