Provider Demographics
NPI:1518021989
Name:WHITESIDE, KATHRYN (OTR)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:WHITESIDE
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:735 CASPER CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:COBDEN
Mailing Address - State:IL
Mailing Address - Zip Code:62920-3619
Mailing Address - Country:US
Mailing Address - Phone:618-833-1506
Mailing Address - Fax:618-833-1308
Practice Address - Street 1:515 E VIENNA ST
Practice Address - Street 2:SUITE I
Practice Address - City:ANNA
Practice Address - State:IL
Practice Address - Zip Code:62906-2029
Practice Address - Country:US
Practice Address - Phone:618-833-1506
Practice Address - Fax:618-833-1308
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist