Basic Information
| Provider Information | |||||||||
| NPI: | 1447636774 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | WHITESIDES | ||||||||
| FirstName: | KEENAN | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 683 BONAVENTURE AVE NE | ||||||||
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| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303064304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9105120085 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1365 CLIFTON RD NE | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303221013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047785000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2015 | ||||||||
| LastUpdateDate: | 08/10/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT011966 | GA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.