Provider Demographics
NPI:1679953467
Name:WHIGHAM, OTIS
Entity type:Individual
Prefix:
First Name:OTIS
Middle Name:
Last Name:WHIGHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3311 OLD FOREST ROAD STE. 101
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501-1312
Mailing Address - Country:US
Mailing Address - Phone:434-363-4815
Mailing Address - Fax:434-688-0184
Practice Address - Street 1:2215 LANGHORNE RD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501
Practice Address - Country:US
Practice Address - Phone:434-948-4831
Practice Address - Fax:434-485-8877
Is Sole Proprietor?:No
Enumeration Date:2015-06-05
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040083941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical