Provider Demographics
NPI:1124352810
Name:STEPHANIE WHITSON CLINICAL PSYCHOLOGIST, LLC
Entity type:Organization
Organization Name:STEPHANIE WHITSON CLINICAL PSYCHOLOGIST, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:WHITSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:478-953-0088
Mailing Address - Street 1:104 BORDERS WAY
Mailing Address - Street 2:SUITE 700
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-8966
Mailing Address - Country:US
Mailing Address - Phone:478-953-0088
Mailing Address - Fax:
Practice Address - Street 1:104 BORDERS WAY
Practice Address - Street 2:SUITE 700
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-8966
Practice Address - Country:US
Practice Address - Phone:478-953-0088
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-28
Last Update Date:2009-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY002828251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA887675424AMedicaid
GA68BBGLCMedicare UPIN