Provider Demographics
NPI:1962715458
Name:WHITTEN, MICHAEL EDWARD (PHD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:EDWARD
Last Name:WHITTEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1028 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40065-1315
Mailing Address - Country:US
Mailing Address - Phone:502-647-2477
Mailing Address - Fax:502-371-0890
Practice Address - Street 1:1028 MAIN ST
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:KY
Practice Address - Zip Code:40065-1315
Practice Address - Country:US
Practice Address - Phone:502-647-2477
Practice Address - Fax:502-371-0890
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-26
Last Update Date:2017-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY129372103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100283810Medicaid