Provider Demographics
NPI:1669943684
Name:WHITAKER, COLETTE (MA)
Entity type:Individual
Prefix:
First Name:COLETTE
Middle Name:
Last Name:WHITAKER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1745 GREVELIA ST APT 15
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-2759
Mailing Address - Country:US
Mailing Address - Phone:323-717-2824
Mailing Address - Fax:
Practice Address - Street 1:211 S PRIMROSE AVE
Practice Address - Street 2:
Practice Address - City:MONROVIA
Practice Address - State:CA
Practice Address - Zip Code:91016-2856
Practice Address - Country:US
Practice Address - Phone:323-717-2824
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA87861101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health