Provider Demographics
NPI:1285840058
Name:WHITMORE, TERRI DALE (PTA)
Entity Type:Individual
Prefix:
First Name:TERRI
Middle Name:DALE
Last Name:WHITMORE
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 1:2964 W MIRMONTE ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-2680
Mailing Address - Country:US
Mailing Address - Phone:208-895-0187
Mailing Address - Fax:
Practice Address - Street 1:1130 ALLUMBAUGH ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8700
Practice Address - Country:US
Practice Address - Phone:208-854-8502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPTA-360225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant