Provider Demographics
NPI:1952394033
Name:WHITEHEAD, DAN (PHD)
Entity type:Individual
Prefix:DR
First Name:DAN
Middle Name:
Last Name:WHITEHEAD
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 489
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:91933-0489
Mailing Address - Country:US
Mailing Address - Phone:619-518-2051
Mailing Address - Fax:619-575-7500
Practice Address - Street 1:2515 CAMINO DEL RIO S
Practice Address - Street 2:SUITE 114
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3792
Practice Address - Country:US
Practice Address - Phone:619-518-2051
Practice Address - Fax:619-518-2051
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-24
Last Update Date:2009-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY13833103G00000X, 103TC0700X, 103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY138330Medicaid
CAPSY138330Medicaid
CACP13833Medicare ID - Type Unspecified