Basic Information
| Provider Information | |||||||||
| NPI: | 1962823153 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHATLEY | ||||||||
| FirstName: | BLAKE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | DPT, ATC/L, M.ED | ||||||||
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| Mailing Information | |||||||||
| Address1: | 39 WHATLEY RD | ||||||||
| Address2: | |||||||||
| City: | MERIGOLD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 387599616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6627195223 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 450 HIGHWAY 12 W STE D | ||||||||
| Address2: | |||||||||
| City: | STARKVILLE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 397593697 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2283885714 | ||||||||
| FaxNumber: | 2283880017 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2013 | ||||||||
| LastUpdateDate: | 08/26/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | AT0488 | MS | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer | 225100000X | PT5634 | MS | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.