Basic Information
| Provider Information | |||||||||
| NPI: | 1619990546 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WHITNEY | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1590 E POLSTON AVE | ||||||||
| Address2: | STE B | ||||||||
| City: | POST FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838545218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087774242 | ||||||||
| FaxNumber: | 2087774020 | ||||||||
| Practice Location | |||||||||
| Address1: | 1590 E POLSTON AVE | ||||||||
| Address2: | STE B | ||||||||
| City: | POST FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838545218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087774242 | ||||||||
| FaxNumber: | 2087774020 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 01/02/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT00007703 | WA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT1365 | ID | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | PT 1365 | 01 | ID | IDAHO LICENSE | OTHER | PENDING | 05 | ID | MEDICAID |