Provider Demographics
NPI:1154637189
Name:WHITTALL, HEATHER T (PSYD)
Entity type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:T
Last Name:WHITTALL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 30TH ST STE 212
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-1087
Mailing Address - Country:US
Mailing Address - Phone:720-591-4664
Mailing Address - Fax:
Practice Address - Street 1:1800 30TH ST STE 212
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-1087
Practice Address - Country:US
Practice Address - Phone:720-591-4664
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-27
Last Update Date:2024-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3829103TC2200X, 103T00000X
CO5803101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO79600573Medicaid
CO022463OtherKAISER COMMERCIAL NUMBER
CO79600573Medicaid