Provider Demographics
NPI:1609480847
Name:WHITTAKER, NICHOLAS TYLER (DPT)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:TYLER
Last Name:WHITTAKER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 BUDS TRL
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04021-3162
Mailing Address - Country:US
Mailing Address - Phone:207-831-1956
Mailing Address - Fax:
Practice Address - Street 1:200 JOHN ROBERTS RD
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-3366
Practice Address - Country:US
Practice Address - Phone:207-831-1956
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-04
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT5750225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist