Provider Demographics
NPI:1295886273
Name:WHITSON, BECKY
Entity type:Individual
Prefix:
First Name:BECKY
Middle Name:
Last Name:WHITSON
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 1:1020 STATE HIGHWAY 278
Mailing Address - Street 2:
Mailing Address - City:GRADY
Mailing Address - State:NM
Mailing Address - Zip Code:88120-9608
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1107 SOUTH ELEVENTH STREET
Practice Address - Street 2:
Practice Address - City:TUCUMCARI
Practice Address - State:NM
Practice Address - Zip Code:88401
Practice Address - Country:US
Practice Address - Phone:505-461-4344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3022235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM00G7836Medicaid