Provider Demographics
NPI:1508651134
Name:WHITESIDE, TAREVA
Entity type:Individual
Prefix:
First Name:TAREVA
Middle Name:
Last Name:WHITESIDE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1536 HOVEY ST
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46406-2341
Mailing Address - Country:US
Mailing Address - Phone:219-302-6594
Mailing Address - Fax:
Practice Address - Street 1:4840 GRASSELLI ST
Practice Address - Street 2:
Practice Address - City:EAST CHICAGO
Practice Address - State:IN
Practice Address - Zip Code:46312-3503
Practice Address - Country:US
Practice Address - Phone:219-937-1085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-14
Last Update Date:2025-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician