Provider Demographics
NPI:1962128397
Name:WOLLWEBER, WHITNEY
Entity type:Individual
Prefix:
First Name:WHITNEY
Middle Name:
Last Name:WOLLWEBER
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 1:3091 N ATLAS RD UNIT H305
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-6363
Mailing Address - Country:US
Mailing Address - Phone:509-995-4501
Mailing Address - Fax:
Practice Address - Street 1:16020 POLENSKE RD N
Practice Address - Street 2:
Practice Address - City:EDWALL
Practice Address - State:WA
Practice Address - Zip Code:99008-9631
Practice Address - Country:US
Practice Address - Phone:509-995-4501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-17
Last Update Date:2024-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-9772101YP2500X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE