1255788840 NPI number — WHITTAKER FAMILY SERVICES, LLC

Table of content: MS. SUSAN MARY DEISROTH LCSW (NPI 1306993498)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255788840 NPI number — WHITTAKER FAMILY SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WHITTAKER FAMILY SERVICES, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1255788840
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/11/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14502 NORTH DALE MABRY HWY
Provider Second Line Business Mailing Address:
SUITE #200
Provider Business Mailing Address City Name:
TAMPA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33618
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-240-0855
Provider Business Mailing Address Fax Number:
727-800-1854

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14502 NORTH DALE MABRY HWY
Provider Second Line Business Practice Location Address:
SUITE #200
Provider Business Practice Location Address City Name:
TAMPA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33618
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-240-0855
Provider Business Practice Location Address Fax Number:
727-800-1854
Provider Enumeration Date:
05/24/2016

Additional Information

Authorized Official

Authorized Official Last Name:
WHITTAKER
Authorized Official First Name:
CHRISTINE
Authorized Official Middle Name:
JENNY
Authorized Official Title or Position:
OWNER/LICENSEDMARRIAGE&FAMILYTHERAP
Authorized Official Telephone Number:
813-240-0855

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  MT3108 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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