Basic Information
| Provider Information | |||||||||
| NPI: | 1083746192 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHYTLAW | ||||||||
| FirstName: | NATALIE | ||||||||
| MiddleName: | REAGAN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MS.CCC.SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4624 GARDEN LN | ||||||||
| Address2: | |||||||||
| City: | ODESSA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 797613518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4322720937 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 620 N ALLEGHANEY AVE | ||||||||
| Address2: | |||||||||
| City: | ODESSA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 797614408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4323328244 | ||||||||
| FaxNumber: | 4325807428 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 100252 | TX | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 8T2673 | 01 | TX | BCBS PROVIDER NUMBER | OTHER | 100252 | 01 | TX | STATE LICENSE NUMBER | OTHER | 132534 | 01 | TX | SUPERIOR PROVIDER NUMBER | OTHER |