Provider Demographics
NPI:1366641037
Name:WHITEHEAD, MICHELE RENEE (PT)
Entity Type:Individual
Prefix:MRS
First Name:MICHELE
Middle Name:RENEE
Last Name:WHITEHEAD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3026 NW 28TH CIR
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605-2983
Mailing Address - Country:US
Mailing Address - Phone:352-562-1166
Mailing Address - Fax:
Practice Address - Street 1:333 1ST ST N
Practice Address - Street 2:SUITE 200
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-6945
Practice Address - Country:US
Practice Address - Phone:904-241-9231
Practice Address - Fax:877-420-5038
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-13
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1166530225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist