Provider Demographics
NPI:1548039100
Name:WHITESIDE, JOEL TYLER (LPC)
Entity type:Individual
Prefix:
First Name:JOEL
Middle Name:TYLER
Last Name:WHITESIDE
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10756 W BUCHANAN ST
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85323-5441
Mailing Address - Country:US
Mailing Address - Phone:360-703-7138
Mailing Address - Fax:
Practice Address - Street 1:10756 W BUCHANAN ST
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85323-5441
Practice Address - Country:US
Practice Address - Phone:360-703-7138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-25
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-22756101YP2500X
AZ22756101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health