Provider Demographics
NPI:1275264681
Name:WHITEHEAD, KELSEY (PTA)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:WHITEHEAD
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 1:2560 NE HOPKINS CT
Mailing Address - Street 2:
Mailing Address - City:PULLMAN
Mailing Address - State:WA
Mailing Address - Zip Code:99163-5622
Mailing Address - Country:US
Mailing Address - Phone:509-338-3800
Mailing Address - Fax:
Practice Address - Street 1:2560 NE HOPKINS CT
Practice Address - Street 2:
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99163-5622
Practice Address - Country:US
Practice Address - Phone:509-338-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-17
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61277542225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant