Provider Demographics
NPI:1174533525
Name:WHITLOCK, ALAN J (PHD)
Entity type:Individual
Prefix:DR
First Name:ALAN
Middle Name:J
Last Name:WHITLOCK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:814 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-3049
Mailing Address - Country:US
Mailing Address - Phone:208-883-4026
Mailing Address - Fax:
Practice Address - Street 1:814 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-3049
Practice Address - Country:US
Practice Address - Phone:208-883-4026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY 340103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDN3405OtherBLUE CROSS OF IDAHO
ID000010017398OtherREGENCE BLUE SHIELD OF ID