1407066855 NPI number — MRS. GLORIA SMITH WHITLEY LCSW

Table of content: MRS. GLORIA SMITH WHITLEY LCSW (NPI 1407066855)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407066855 NPI number — MRS. GLORIA SMITH WHITLEY LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WHITLEY
Provider First Name:
GLORIA
Provider Middle Name:
SMITH
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407066855
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 31234
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39286-1234
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-201-4189
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
405 BRIARWOOD DR
Provider Second Line Business Practice Location Address:
BUILDINGA SUITE 106-E
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39206-3052
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-991-3156
Provider Business Practice Location Address Fax Number:
601-991-3157
Provider Enumeration Date:
05/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  CO793 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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