Provider Demographics
NPI:1477686665
Name:WHITLEY, REBECCA SUSAN
Entity type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:SUSAN
Last Name:WHITLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:REBECCA
Other - Middle Name:SUSAN
Other - Last Name:WHITLEY LOCKHART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:218 BRECKINRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:VERSAILLES
Mailing Address - State:KY
Mailing Address - Zip Code:40383-1239
Mailing Address - Country:US
Mailing Address - Phone:859-533-5434
Mailing Address - Fax:
Practice Address - Street 1:218 BRECKINRIDGE DR
Practice Address - Street 2:
Practice Address - City:VERSAILLES
Practice Address - State:KY
Practice Address - Zip Code:40383-1239
Practice Address - Country:US
Practice Address - Phone:502-465-5005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2542321041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100605830Medicaid