Basic Information
| Provider Information | |||||||||
| NPI: | 1619468501 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHITEHEAD | ||||||||
| FirstName: | AISHAH | ||||||||
| MiddleName: | RENEE | ||||||||
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| Credential: | LCSWA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 419 TYLER TRAIL CT APT 222 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282623393 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708957580 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5200 PARK RD STE 218B | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282093650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8667001606 | ||||||||
| FaxNumber: | 8663385921 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2018 | ||||||||
| LastUpdateDate: | 05/25/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | P011394 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.