Provider Demographics
NPI:1487245221
Name:WHITAKER, COLLEEN (MED BCBA LBA)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:WHITAKER
Suffix:
Gender:F
Credentials:MED BCBA LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 WIREGRASS LN
Mailing Address - Street 2:
Mailing Address - City:SOUTHERN PINES
Mailing Address - State:NC
Mailing Address - Zip Code:28387-3062
Mailing Address - Country:US
Mailing Address - Phone:925-785-8986
Mailing Address - Fax:
Practice Address - Street 1:11614 SEVEN LOCKS RD
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20854-3261
Practice Address - Country:US
Practice Address - Phone:301-469-0223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-02
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD250103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1-16-22211OtherBCBA