Provider Demographics
NPI:1962994038
Name:WHITAKER, IDA LUCILLE
Entity type:Individual
Prefix:MRS
First Name:IDA
Middle Name:LUCILLE
Last Name:WHITAKER
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 1:615 ALLISON LN
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92069-6516
Mailing Address - Country:US
Mailing Address - Phone:619-454-0602
Mailing Address - Fax:
Practice Address - Street 1:1002 E GRAND AVE
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-4605
Practice Address - Country:US
Practice Address - Phone:760-741-2660
Practice Address - Fax:760-741-2647
Is Sole Proprietor?:No
Enumeration Date:2018-06-04
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA100567106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist