Basic Information
| Provider Information | |||||||||
| NPI: | 1023641644 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | WHITESIDE | ||||||||
| FirstName: | ALEXIS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 131 S THALIA RD | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234521230 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 ANNA GOODE WAY | ||||||||
| Address2: | |||||||||
| City: | SUFFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234349236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7579235500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2020 | ||||||||
| LastUpdateDate: | 02/10/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 01/20/2021 | ||||||||
| NPIReactivationDate: | 02/09/2021 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 0119008860 | VA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.