Provider Demographics
NPI:1477378941
Name:WHITTEN, DETRIS (LMSW)
Entity type:Individual
Prefix:
First Name:DETRIS
Middle Name:
Last Name:WHITTEN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7579 WOODSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:HORN LAKE
Mailing Address - State:MS
Mailing Address - Zip Code:38637-5104
Mailing Address - Country:US
Mailing Address - Phone:662-288-8178
Mailing Address - Fax:
Practice Address - Street 1:1122 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38106-2204
Practice Address - Country:US
Practice Address - Phone:901-448-9883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-20
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN131145104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker