Provider Demographics
NPI:1356552012
Name:WHITEHEAD, DANNY (LICSW)
Entity type:Individual
Prefix:MR
First Name:DANNY
Middle Name:
Last Name:WHITEHEAD
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 883
Mailing Address - Street 2:
Mailing Address - City:DEVILS LAKE
Mailing Address - State:ND
Mailing Address - Zip Code:58301-0883
Mailing Address - Country:US
Mailing Address - Phone:701-662-8255
Mailing Address - Fax:701-662-1739
Practice Address - Street 1:211 4TH ST NE
Practice Address - Street 2:STE 4
Practice Address - City:DEVILS LAKE
Practice Address - State:ND
Practice Address - Zip Code:58301-2479
Practice Address - Country:US
Practice Address - Phone:701-662-8255
Practice Address - Fax:701-662-1739
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2009-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND43701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND19260Medicaid
NDN714543Medicare PIN