Provider Demographics
NPI:1063070209
Name:WHITAKER, SUSAN MICHELE (LCDC INTERN)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:MICHELE
Last Name:WHITAKER
Suffix:
Gender:F
Credentials:LCDC INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 JORDAN PLAZA BLVD STE 302
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75704-2056
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:THE BEGINNING
Practice Address - Street 2:114 JORDAN PLAZA BLVD SUITE 302
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75704
Practice Address - Country:US
Practice Address - Phone:903-581-9472
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-03
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)