Provider Demographics
NPI:1619990546
Name:WHITNEY, MICHAEL D (PT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:WHITNEY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1590 E POLSTON AVE
Mailing Address - Street 2:STE B
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-5218
Mailing Address - Country:US
Mailing Address - Phone:208-777-4242
Mailing Address - Fax:208-777-4020
Practice Address - Street 1:1590 E POLSTON AVE
Practice Address - Street 2:STE B
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-5218
Practice Address - Country:US
Practice Address - Phone:208-777-4242
Practice Address - Fax:208-777-4020
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2008-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00007703225100000X
IDPT1365225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDPT 1365OtherIDAHO LICENSE
IDPENDINGMedicaid
IDPENDINGMedicaid