Basic Information
| Provider Information | |||||||||
| NPI: | 1396999306 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHITTINGHAM | ||||||||
| FirstName: | EDWINA | ||||||||
| MiddleName: | LENORA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KNOX-BETTY | ||||||||
| OtherFirstName: | EDWINA | ||||||||
| OtherMiddleName: | LENORA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LCSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2530 OLD SALEM CIR SE | ||||||||
| Address2: | |||||||||
| City: | CONYERS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300132454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709188348 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1808 OVER LAKE DR SE STE D | ||||||||
| Address2: | |||||||||
| City: | CONYERS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300136608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6782132194 | ||||||||
| FaxNumber: | 6789227767 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2008 | ||||||||
| LastUpdateDate: | 06/25/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | CSW003478 | GA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.