Basic Information
| Provider Information | |||||||||
| NPI: | 1598165516 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHITEHALL | ||||||||
| FirstName: | BARBARA | ||||||||
| MiddleName: | YVONNE | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DIXON-WHITEHALL | ||||||||
| OtherFirstName: | BARBARA | ||||||||
| OtherMiddleName: | YVONNE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 215 N MAGNOLIA ST | ||||||||
| Address2: | |||||||||
| City: | SUMTER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291504943 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037759364 | ||||||||
| FaxNumber: | 8037736615 | ||||||||
| Practice Location | |||||||||
| Address1: | 2611 LIBERTY HILL RD | ||||||||
| Address2: | |||||||||
| City: | CAMDEN | ||||||||
| State: | SC | ||||||||
| PostalCode: | 290201871 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034325323 | ||||||||
| FaxNumber: | 8037133978 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2014 | ||||||||
| LastUpdateDate: | 08/27/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 0273 | SC | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 18566 | MD | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 457633 | 05 | SC | MEDICAID |