Provider Demographics
NPI:1699254961
Name:WHITLOCK, CLYDE THOMAS JR
Entity type:Individual
Prefix:
First Name:CLYDE
Middle Name:THOMAS
Last Name:WHITLOCK
Suffix:JR
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 1:4009 FITZHUGH AVE STE 203
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23230-3953
Mailing Address - Country:US
Mailing Address - Phone:804-658-2784
Mailing Address - Fax:804-658-2793
Practice Address - Street 1:4009 FITZHUGH AVE STE 203
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23230-3953
Practice Address - Country:US
Practice Address - Phone:804-658-2784
Practice Address - Fax:804-658-2793
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-08
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0698505028251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0698505028Medicaid