Provider Demographics
NPI:1780134189
Name:WHITMORE, TERESSA GAYE (LAC)
Entity type:Individual
Prefix:
First Name:TERESSA
Middle Name:GAYE
Last Name:WHITMORE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:TERESSA
Other - Middle Name:
Other - Last Name:WHITMORE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:QBHP
Mailing Address - Street 1:1310 W MAIN ST STE 201
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801-2803
Mailing Address - Country:US
Mailing Address - Phone:479-967-2001
Mailing Address - Fax:
Practice Address - Street 1:1 LILE CT STE 200
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-6240
Practice Address - Country:US
Practice Address - Phone:501-683-1837
Practice Address - Fax:501-683-1839
Is Sole Proprietor?:No
Enumeration Date:2016-10-10
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP2403007101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR171615795Medicaid