Provider Demographics
NPI:1558310615
Name:WHITESIDE, DIANE (PT)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:WHITESIDE
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:PO BOX 612260
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95161-2260
Mailing Address - Country:US
Mailing Address - Phone:877-325-2776
Mailing Address - Fax:408-945-4011
Practice Address - Street 1:350 BOLLINGER CANYON LN
Practice Address - Street 2:STE A
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94582-4592
Practice Address - Country:US
Practice Address - Phone:925-735-6414
Practice Address - Fax:925-735-6450
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 8701225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist