Provider Demographics
NPI:1528606266
Name:WHITLEY, MICHAEL (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:WHITLEY
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2248 BROADWAY # 1243
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10024-5805
Mailing Address - Country:US
Mailing Address - Phone:347-201-6815
Mailing Address - Fax:725-567-4149
Practice Address - Street 1:2248 BROADWAY # 1243
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-5805
Practice Address - Country:US
Practice Address - Phone:347-201-6815
Practice Address - Fax:725-567-4149
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-12
Last Update Date:2025-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY405634363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health