Provider Demographics
NPI:1144589813
Name:WITLAM, ANGELIQUE (PT, DPT, ATP)
Entity Type:Individual
Prefix:DR
First Name:ANGELIQUE
Middle Name:
Last Name:WITLAM
Suffix:
Gender:F
Credentials:PT, DPT, ATP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2380 S ROBERTS WAY
Mailing Address - Street 2:
Mailing Address - City:LOGANSPORT
Mailing Address - State:IN
Mailing Address - Zip Code:46947-6626
Mailing Address - Country:US
Mailing Address - Phone:574-753-0466
Mailing Address - Fax:
Practice Address - Street 1:906 W. EXECUTIVE COURT
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:IN
Practice Address - Zip Code:47960
Practice Address - Country:US
Practice Address - Phone:574-583-9950
Practice Address - Fax:574-583-9951
Is Sole Proprietor?:No
Enumeration Date:2012-05-15
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05005405A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist