Provider Demographics
NPI:1811614308
Name:WHITEHEAD, BRYN
Entity type:Individual
Prefix:
First Name:BRYN
Middle Name:
Last Name:WHITEHEAD
Suffix:
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 1:1801 W WARNER AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-1891
Mailing Address - Country:US
Mailing Address - Phone:312-940-2190
Mailing Address - Fax:
Practice Address - Street 1:1801 W WARNER AVE STE 101
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-1891
Practice Address - Country:US
Practice Address - Phone:312-940-2190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-25
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician