Provider Demographics
NPI:1538450432
Name:WHITTEN, KEITA A (LMSW-CC)
Entity type:Individual
Prefix:
First Name:KEITA
Middle Name:A
Last Name:WHITTEN
Suffix:
Gender:F
Credentials:LMSW-CC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:470 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-2009
Mailing Address - Country:US
Mailing Address - Phone:207-854-1030
Mailing Address - Fax:207-899-4623
Practice Address - Street 1:470 FOREST AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-2009
Practice Address - Country:US
Practice Address - Phone:207-874-1030
Practice Address - Fax:207-899-4623
Is Sole Proprietor?:No
Enumeration Date:2011-04-26
Last Update Date:2013-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMC12864104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker