Provider Demographics
NPI:1407519879
Name:WHITE, DAVID KENNETH (PTA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:KENNETH
Last Name:WHITE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33900 HARPER AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-4258
Mailing Address - Country:US
Mailing Address - Phone:586-350-2644
Mailing Address - Fax:586-541-3735
Practice Address - Street 1:1867 HARVARD AVE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30337-3526
Practice Address - Country:US
Practice Address - Phone:404-835-4321
Practice Address - Fax:404-835-4320
Is Sole Proprietor?:No
Enumeration Date:2021-10-21
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502006446225200000X
GAPTA004816225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant