Provider Demographics
NPI:1205536018
Name:WHITTAKER, SAMUEL WARREN
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:WARREN
Last Name:WHITTAKER
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 1:104 BRIGHTON KNOLL CT
Mailing Address - Street 2:
Mailing Address - City:ACCOKEEK
Mailing Address - State:MD
Mailing Address - Zip Code:20607-2718
Mailing Address - Country:US
Mailing Address - Phone:202-997-4631
Mailing Address - Fax:
Practice Address - Street 1:104 BRIGHTON KNOLL CT
Practice Address - Street 2:
Practice Address - City:ACCOKEEK
Practice Address - State:MD
Practice Address - Zip Code:20607-2718
Practice Address - Country:US
Practice Address - Phone:202-997-4631
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-09
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC261QM0801X
171M00000X
DC965261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)