Provider Demographics
NPI:1528664950
Name:WHITAKER, THERESA (PHD)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:WHITAKER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1775 MASSACHUSETTS AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02420-5322
Mailing Address - Country:US
Mailing Address - Phone:315-404-9554
Mailing Address - Fax:
Practice Address - Street 1:1775 MASSACHUSETTS AVE STE 3
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:MA
Practice Address - Zip Code:02420-5322
Practice Address - Country:US
Practice Address - Phone:315-404-9554
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-10
Last Update Date:2025-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11603103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
00000000OtherN/A