Provider Demographics
NPI:1649790254
Name:WHITAKER, THOMAS
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:WHITAKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13669 HORNET WAY APT 402
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-5232
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13669 HORNET WAY APT 402
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-5232
Practice Address - Country:US
Practice Address - Phone:703-203-1699
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-24
Last Update Date:2017-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education