Provider Demographics
NPI:1952442741
Name:MARIE ANDERSEN-WHITEHURST
Entity Type:Organization
Organization Name:MARIE ANDERSEN-WHITEHURST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSEN-WHITEHURST
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:336-662-8185
Mailing Address - Street 1:5729 OLD RANDLEMAN RD
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27406-8808
Mailing Address - Country:US
Mailing Address - Phone:336-662-8185
Mailing Address - Fax:336-665-6188
Practice Address - Street 1:5729 OLD RANDLEMAN RD
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27406-8808
Practice Address - Country:US
Practice Address - Phone:336-662-8185
Practice Address - Fax:336-665-6188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0011721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC11249OtherBCBS
NC11249OtherBCBS
NC=========OtherTRICARE