Provider Demographics
NPI:1205656964
Name:WHITEHEAD, MATTHEW BRUCE
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:BRUCE
Last Name:WHITEHEAD
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 1:2502 W TEXAS AVE UNIT A
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33629-6223
Mailing Address - Country:US
Mailing Address - Phone:850-257-3122
Mailing Address - Fax:
Practice Address - Street 1:1111 N WEST SHORE BLVD STE 213
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-4711
Practice Address - Country:US
Practice Address - Phone:850-257-3122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-16
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH26461101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health