Provider Demographics
NPI:1245497403
Name:WHITEHURST, WANDA
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:WHITEHURST
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 1:461 W 164TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-8109
Mailing Address - Country:US
Mailing Address - Phone:347-825-4882
Mailing Address - Fax:
Practice Address - Street 1:461 W 164TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-8109
Practice Address - Country:US
Practice Address - Phone:347-825-4882
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-16
Last Update Date:2015-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02740141Medicaid