Provider Demographics
NPI:1831245745
Name:WHITLEY, RONALD G (MA,LMFT)
Entity type:Individual
Prefix:MR
First Name:RONALD
Middle Name:G
Last Name:WHITLEY
Suffix:
Gender:M
Credentials:MA,LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 WINDHAM LN
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28540-4076
Mailing Address - Country:US
Mailing Address - Phone:910-546-5809
Mailing Address - Fax:910-347-2129
Practice Address - Street 1:825 GUM BRANCH RD
Practice Address - Street 2:SUITE 128-D
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28540-6298
Practice Address - Country:US
Practice Address - Phone:910-546-5809
Practice Address - Fax:910-347-2129
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC481106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6105152Medicaid