Provider Demographics
NPI:1699803692
Name:WHITTAKER, SUSAN MARIE (PMHNP-BC)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:MARIE
Last Name:WHITTAKER
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:MARIE
Other - Last Name:BRILL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PMHNP-BC
Mailing Address - Street 1:7232 JUSTIN WAY
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-4881
Mailing Address - Country:US
Mailing Address - Phone:440-578-8200
Mailing Address - Fax:
Practice Address - Street 1:7232 JUSTIN WAY
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-4881
Practice Address - Country:US
Practice Address - Phone:440-578-8200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN 315915163WP0809X
OHAPRN.CNP.12685363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0064383Medicaid