Provider Demographics
NPI:1679702666
Name:WHITEHEAD, DARA JO (MS, CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:DARA
Middle Name:JO
Last Name:WHITEHEAD
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9600 ESCARPMENT BLVD
Mailing Address - Street 2:745-125
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78749-1982
Mailing Address - Country:US
Mailing Address - Phone:512-466-5013
Mailing Address - Fax:
Practice Address - Street 1:4315 JAMES CASEY ST
Practice Address - Street 2:SUITE 300
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78745-3364
Practice Address - Country:US
Practice Address - Phone:512-466-5013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-10
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX103264235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist