Provider Demographics
NPI:1477174928
Name:WHITEHEAD, TINA (LMT)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:WHITEHEAD
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 LYNN LN APT 17B
Mailing Address - Street 2:
Mailing Address - City:STARKVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39759-3979
Mailing Address - Country:US
Mailing Address - Phone:662-769-1143
Mailing Address - Fax:
Practice Address - Street 1:518 HWY 12 W
Practice Address - Street 2:
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759
Practice Address - Country:US
Practice Address - Phone:662-769-1143
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-06
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2732225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist