Provider Demographics
NPI:1306504196
Name:WHITFIELD, THOMAS EISENHOWER
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:EISENHOWER
Last Name:WHITFIELD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CARL VINSON VA
Mailing Address - Street 2:1826 VETERANS BLVD
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31021
Mailing Address - Country:US
Mailing Address - Phone:478-272-1210
Mailing Address - Fax:
Practice Address - Street 1:109 PINERIDGE ST
Practice Address - Street 2:
Practice Address - City:TENNILLE
Practice Address - State:GA
Practice Address - Zip Code:31089-2247
Practice Address - Country:US
Practice Address - Phone:478-247-6131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-30
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC007968101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health