Provider Demographics
NPI:1932617578
Name:WHITEHEAD, TARSHA
Entity type:Individual
Prefix:
First Name:TARSHA
Middle Name:
Last Name:WHITEHEAD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2725 HIGHWAY 51 S
Mailing Address - Street 2:
Mailing Address - City:HERNANDO
Mailing Address - State:MS
Mailing Address - Zip Code:38632-2634
Mailing Address - Country:US
Mailing Address - Phone:662-449-1880
Mailing Address - Fax:
Practice Address - Street 1:2725 HIGHWAY 51 S
Practice Address - Street 2:
Practice Address - City:HERNANDO
Practice Address - State:MS
Practice Address - Zip Code:38632-2634
Practice Address - Country:US
Practice Address - Phone:662-449-1880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-17
Last Update Date:2018-01-24
Deactivation Date:2018-01-18
Deactivation Code:
Reactivation Date:2018-01-24
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS262449011Medicaid