Provider Demographics
NPI:1477269751
Name:WHITEHEAD, BRIAN (PTA)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:
Last Name:WHITEHEAD
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 1:266 MEADOW SAFFRON DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29073-9764
Mailing Address - Country:US
Mailing Address - Phone:803-457-1678
Mailing Address - Fax:
Practice Address - Street 1:266 MEADOW SAFFRON DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29073-9764
Practice Address - Country:US
Practice Address - Phone:803-457-1678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-30
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5046225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant