Provider Demographics
NPI:1245035534
Name:WHITEHEAD, SAMONNE A (MSW, ADT)
Entity type:Individual
Prefix:
First Name:SAMONNE
Middle Name:A
Last Name:WHITEHEAD
Suffix:
Gender:
Credentials:MSW, ADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3310 EASTERN AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21224-4108
Mailing Address - Country:US
Mailing Address - Phone:443-708-5056
Mailing Address - Fax:
Practice Address - Street 1:3310 EASTERN AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224-4108
Practice Address - Country:US
Practice Address - Phone:443-708-5056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-19
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDADT2846101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor