Basic Information
Provider Information | |||||||||
NPI: | 1629140827 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WHITESIDE | ||||||||
FirstName: | MARY | ||||||||
MiddleName: | CATHARINE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1 OAK PLZ | ||||||||
Address2: | SUITE 206 | ||||||||
City: | ASHEVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 288013008 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8282522501 | ||||||||
FaxNumber: | 8282522701 | ||||||||
Practice Location | |||||||||
Address1: | 1 OAK PLZ | ||||||||
Address2: | SUITE 206 | ||||||||
City: | ASHEVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 288013008 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8282522501 | ||||||||
FaxNumber: | 8282522701 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/14/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | C004308 | NC | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | 13281 | 01 | NC | BCBS | OTHER | 6002528 | 05 | NC |   | MEDICAID |