Provider Demographics
NPI:1164668976
Name:WHITE, TALICIA JANE (PTA)
Entity Type:Individual
Prefix:
First Name:TALICIA
Middle Name:JANE
Last Name:WHITE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 MERCHANTS WALK
Mailing Address - Street 2:
Mailing Address - City:SUMMERSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26651-1901
Mailing Address - Country:US
Mailing Address - Phone:304-872-7498
Mailing Address - Fax:304-872-8144
Practice Address - Street 1:207 MERCHANTS WALK
Practice Address - Street 2:
Practice Address - City:SUMMERSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26651-1901
Practice Address - Country:US
Practice Address - Phone:304-872-7498
Practice Address - Fax:304-872-8144
Is Sole Proprietor?:No
Enumeration Date:2008-12-29
Last Update Date:2008-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVPTA001447225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant