Provider Demographics
NPI:1770963639
Name:WHITLEY, VICKIE (LCSWA)
Entity type:Individual
Prefix:
First Name:VICKIE
Middle Name:
Last Name:WHITLEY
Suffix:
Gender:F
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 HENDRIX DR
Mailing Address - Street 2:
Mailing Address - City:KERNERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27284-3016
Mailing Address - Country:US
Mailing Address - Phone:336-972-2156
Mailing Address - Fax:
Practice Address - Street 1:116 HENDRIX DR
Practice Address - Street 2:
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-3016
Practice Address - Country:US
Practice Address - Phone:336-972-2156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-05
Last Update Date:2021-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0095801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1770963639Medicaid