Provider Demographics
NPI:1245565951
Name:WHITTENBERG, CLINTON ALLEN (LMT)
Entity Type:Individual
Prefix:MR
First Name:CLINTON
Middle Name:ALLEN
Last Name:WHITTENBERG
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 101
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:KY
Mailing Address - Zip Code:40031-0101
Mailing Address - Country:US
Mailing Address - Phone:502-222-7623
Mailing Address - Fax:
Practice Address - Street 1:520 JERICHO RD.
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:KY
Practice Address - Zip Code:40031-0101
Practice Address - Country:US
Practice Address - Phone:502-222-7623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-14
Last Update Date:2009-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY0384225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist