Provider Demographics
NPI:1114360823
Name:WHITEHEAD, CHARNETTA KRISTIN YVONNE
Entity type:Individual
Prefix:
First Name:CHARNETTA
Middle Name:KRISTIN YVONNE
Last Name:WHITEHEAD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHARNETTA
Other - Middle Name:KRISTIN YVONNE
Other - Last Name:EPPS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:12530 FAIRWOOD PKWY STE 102
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20720-6357
Mailing Address - Country:US
Mailing Address - Phone:216-903-5655
Mailing Address - Fax:
Practice Address - Street 1:12530 FAIRWOOD PKWY STE 102
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20720-6357
Practice Address - Country:US
Practice Address - Phone:216-903-5655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-11
Last Update Date:2025-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLBA642103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst