Provider Demographics
NPI:1366656274
Name:WHITLOCK, BARBARA L (MED)
Entity type:Individual
Prefix:
First Name:BARBARA
Middle Name:L
Last Name:WHITLOCK
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 N. VIRGINIA
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-5126
Mailing Address - Country:US
Mailing Address - Phone:575-623-9322
Mailing Address - Fax:575-627-6339
Practice Address - Street 1:1010 N. VIRGINIA
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5126
Practice Address - Country:US
Practice Address - Phone:575-623-9322
Practice Address - Fax:575-627-6339
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1760101YP2500X
NM0128911101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM92600824Medicaid