Provider Demographics
NPI:1730165978
Name:WHITTAKER, DOUGLAS LYNN (LCSW)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:LYNN
Last Name:WHITTAKER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4084 FOUBERT AVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-3411
Mailing Address - Country:US
Mailing Address - Phone:801-278-7453
Mailing Address - Fax:
Practice Address - Street 1:7434 S STATE ST
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-2014
Practice Address - Country:US
Practice Address - Phone:801-566-4423
Practice Address - Fax:801-566-4779
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT126368-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT94293834BLYNOtherEDUCATORS MUTUAL
UT107032362101OtherINTRMTN. HEALTH CARE
UT827403OtherDESERET MUTUAL
UT942938348003OtherCHAMPUS
UTR88031OtherMEDICARE ADVANAGE PLANS
UT827403OtherDESERET MUTUAL